Impact of the COVID-19 Pandemic on Urology

Practice in Indonesia: A Nationwide Survey

Nur Rasyid  (  [email protected] )
Cipto Mangunkusumo Hospital https://orcid.org/0000-0003-4473-755X
Ponco Birowo 
Cipto Mangunkusumo Hospital - Faculty of Medicine Universitas Indonesia
Dyandra Parikesit 
Universitas Indonesia Hospital - Faculty of Medicine Universitas Indonesia
Fakhri Rahman 
Cipto Mangunkusumo Hospital - Faculty of Medicine Universitas Indonesia

Research article

Keywords: COVID-19, urology, elective surgery, personal protective equipment

DOI: https://doi.org/10.21203/rs.3.rs-33699/v1

License:   This work is licensed under a Creative Commons Attribution 4.0 International License.  
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Abstract
Background.

Coronavirus disease 2019 (COVID-19) has affected daily practices in health care services. This study
aimed to investigate the impact of COVID-19 on urology practice in Indonesia.

Methods.

This was a cross-sectional study using web-based questionnaire (Survey Monkey), which was distributed
and collected within a period of three weeks. All practicing urologists in Indonesia were sent an e-
questionnaire link via E-mail, WhatsApp Messenger application, and/or short message service, and the
chief of residents in each urology centre distributed the e-questionnaire to urology residents.

Results

The response rate was 369/485 (76%) among urologists and 220/220 (100%) among urology residents.
Less than 10 percent of the responses in each section were incomplete. There are 35/369 (9.5%) Nine
percent of urologists and 59/220 (26.8%) of urology residents had been suspected as COVID-19 patients,
of whom seven of them were con rmed to be COVID-19 positive. The majority of urologists (66%)
preferred to continue face-to-face consultations with a limited number of patients, and more than 60% of
urologists preferred to postpone the majority (66%) or all elective surgery. Most urologists also chose to
postpone elective surgery in patient with COVID-19-related symptoms and patient who required post-
operative ICU-care. Urologist and urology residents reported high rates of using personal protective
equipment, except for medical gowns and N95 masks, which were in short supply. Several uro-oncology
surgeries were considered to be the top priority for Indonesian urologist during COVID-19 epidemic period.

Conclusion.

The COVID-19 pandemic has had a major impact on urology practice in Indonesia.

Background
Firstly discovered on December 2019 in Wuhan, China, coronavirus disease 2019 (COVID-19) has spread
rapidly and widely throughout the world. The World Health Organization (WHO) to declared a pandemic
on 11 March 2020.1,2 The rst positive case in Indonesia was con rmed in early March 2020, the number
has increased exponentially with more than 10,000 cases and almost eight percent mortality rate within
two months.3 This number of cases diagnosed in Indonesia is considered to be the “tip of the iceberg”
and the number of cases is expected to continue to rise.

COVID-19 is caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), a single
stranded ribonucleic acid (RNA) genetically similar to Sarbecovirus. and SARS-CoV-2 infection causes a
wide range of clinical feature, from benign upper respiratory symptoms to deadly acute respiratory

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distress syndrome (ARDS).4–6 Infection is very contagious and is transmitted from human-to-human via
droplets or direct contact.7 Moreover, individuals with positive SARS-CoV-2 infection can be
asymptomatic, have non-respiratory symptoms, and can act as carriers.8,9 Therefore, this pandemic has
forced changes in many aspects of life, including healthcare practices.

Adjustments to this emerging situation are vital to healthcare providers in order to provide the best service
to patients during the pandemic, while still maintaining the highest possible safety. Even though
management of COVID-19 is a “different eld” to urology practice, COVID-19 is having a great impact on
daily urology practice. Several recommendations have been published on adapting to the current
pandemic. They cover several aspects of daily practice, such outpatient clinics, surgeries, and utilization
of personal protective equipment (PPE).10,11 Virtual clinics or use of tele-consultation use for outpatient
clinics and postponement of non-urgent elective surgery are recommended.12

In Cipto Mangunkusumo Hospital, Indonesia’s national referral hospital, COVID-19 has greatly affected
daily practices in many elds, including urology. Direct consultation in the outpatient clinic and elective
surgery are still being performed, but with careful patient selection and restrictions. However, more data
are needed to evaluate the extent of this situation and how it affects urology practices in other hospitals
and whether other urologists also made these adjustments. Thus, this study is aimed to investigate the
impact of the COVID-19 pandemic on urology practice in Indonesia.

Methods
Study Design and Population
This cross-sectional questionnaire-based survey and was conducted in April 2020. The survey targeted
urologists registered in the Indonesian Urology Association (IUA) database and active urology residents in
all centres across Indonesia. Retired urologists or those who have not practiced urology for more than 3
months were excluded. Urology residents who had not entered hospital rotation were also excluded.
Questionnaire construction
The questionnaire was prepared using Survey Monkey (www.surveymonkey.com), a cloud-based online
survey and contained several sections including respondent demographics, public and private hospital
urology practice, and surgery priority assessment. Some of the questions were adapted from
questionnaire developed by Societe Internationale d’ Urologie (SIU).13,14 All questions were written in
Bahasa Indonesia.

The rst section contained questions on respondent demographic characteristics and COVID-19 status. In
addition to age and occupation (urologist or urology resident), this section asked about the respondent’s
COVID-19-related history and whether they had ever been examined for COVID-19. The second section
explored the pattern of urology practice during the outbreak, in terms of outpatient clinics, surgery, and
PPE utilization. This section contained questions on the number of patients in outpatient clinics and the
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number of surgeries before and after the start of the COVID-19 epidemic. It also assessed respondent
attitudes towards COVID-19-related symptoms and post-operative ICU care of patients undergoing
elective (including laparoscopic) and emergency surgery. Last, this section also asked about the
availability and utilization of PPE in both public and private hospitals. The last section assessed
prioritisation of surgery and investigated other impacts of COVID-19.

The questionnaire was designed to require that respondents completed all the questions within each
section before continuing to the next section.

Data collection
Data were collected within a three-week period (from April 8 to 24, 2020) and e-questionnaire link was
delivered via e-mail, WhatsApp Messenger (WA) application (WhatsApp Inc.), and/or short message
service (SMS). E-mail was sent through an IUA account to all registered urologists twice with the second
email message delivered one week after the rst email message. The WA application/SMS applications
were used every three days for a total of six mailings. The rst message via WA application/SMS was
sent three days after the rst email and the last message was sent the day before the deadline date. For
urology residents, the e-questionnaire was distributed and followed up by the chief of resident in each
urology center. Further information outside the questionnaire was obtained through interviews with the
chief of residents.

All respondents were required to ll out their name or enter a unique code, which was given with the WA
application/SMS message to prevent data duplication. The questionnaire contained a statement
promising respondent con dentiality.

Data analysis and reporting

Data analysis was carried out using SPSS Version 23 (IBM Corp, Armonk, NY, USA). The four sections of
the questionnaire were categorized into seven subsections for reporting the results: (1) respondent
demographics and COVID-19-related characteristics, (2) general working conditions during the COVID-19
epidemic, (3) outpatient clinics, (4) types of surgery, (5) PPE, (6) selection and prioritisation of surgery,
and (7) other COVID-19 impacts. Numeric data was presented as mean if it had normal data distribution
and as median if it had abnormal data distribution. The percentage of respondents providing a given
answer was calculated individually for each question so as to exclude questionnaires with missing
responses from the denominator. The distribution of respondents was mapped and this map was
combined with COVID-19 prevalence as of 26 April 2020. As mass testing using polymerase chain
reaction (PCR) was not available in Indonesia, suspected cases were strati ed into person-in-monitoring
(PIM) and patient under surveillance (PUS). A PIM was de ned as a person who exhibited COVID-19
related symptoms, such as fever or respiratory symptoms without pneumonia, and had a history of close
contact with someone with con rmed COVID-19 or had travelled to areas where COVID-19 local
transmission had been reported. A PUS was de ned as a PIM with pneumonia symptoms.15 Tables and
graphs were used to report the results to facilitate their interpretation. The results also contained a
subgroup analysis of the responses of respondents aged 60 years and older.
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Results
Of the total of 502 registered urologists within the IUA database, two urologists had not practiced urology
for more than three months and 15 newly graduated urologists had not yet worked as an urologist
leaving 485 eligible urologist respondents for this study. There were 247 registered urology residents from
six centres in Indonesia, but only 220 residents had entered a clinical rotation in hospital and were eligible
for the survey. A total of 369 urologists (76% response rate) and 220 urology residents (100% response
rate) participated in this study with 89.7% and 97.7% overall completeness, respectively.

Respondent demographics and COVID-19-related

characteristics
Urologist respondents who lled out the questionnaire came from 30 out of 34 provinces (Fig. 1). The
characteristics of respondents and their COVID-19 related information are shown in Table 1. One urologist
and ve urology residents had tested positive using PCR testing of a swab specimen. One other urologist
had tested positive using a rapid test and was still waiting for his swab test result when lling out this
questionnaire

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 Table 1
Respondent’s demographic and COVID-19 characteristics
Characteristics Urologist Urology Resident

N 369 220

Age (years old), median (range) 40 (30–77) 30 (24–38)

COVID-19- related history, n (%) 7 (1.9) 8 (3.6)

Fever 37 (10) 63 (28.6)

Respiratory tract symptoms 8 (2.2) 16 (7.3)

Both fever and respiratory symptom 18 (14.9) 35 (15.9)

Close contact to COVID-19 patient 40 (10.8) 21 (9.5)

Travel history to the area with local transmission

Respondent underwent COVID-19 examination, n (%) 91 (24.7) 16 (7.3)

Rapid test 35 (9.5) 29 (13.2)

PCR / swab test

COVID-19 respondent status, n (%) 28 (7.6) 52 (23.6)

PIM 7 (1.9) 7 (3.2)

PUS 2 (0.5) 5 (2.3)

Positive

Quarantine respondents among suspected case, n (%) 21 / 35 (60) 37 / 59 (62.7)

Hospitalized respondents among suspected case, n (%) 2 / 35 (5.7) 5 / 59 (8.5)

COVID-19, Coronavirus disease 2019; PCR, polymerase chain reaction; PIM, person-in-monitoring; PUS,
patient under surveillance

General working condition during the COVID-19 period

There were 18, 97, and 243 urologist respondents who worked at public hospitals only, private hospitals
only, and both types of hospital, respectively. However, among respondents who worked at both hospitals,
18 respondents did not complete the private hospital practice section of the questionnaire, thus, a total of
261 (70.7%) and 322 (87.2%) respondents worked at public and private hospitals, respectively. Almost
60% respondents worked in a COVID-19 referral public hospital.

Several strategies had been developed by urologists and their hospitals to adjust towards the COVID-19
epidemic situation, such as physician rotation (37% at public hospital and 4.3% at private hospital) and
reduction of working hours (57.9% at public hospital and 53.7% at private hospital). However, 27.6% of
respondents were the only urologist at their hospital and 33,2% had reduced their working hours as their

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primary adjustment. Of the respondents who worked in public hospitals, ve (1.9%) had stopped all their
urology practice all together, but two of them had continued to practice in a private hospital. Of the
respondents who worked in private hospitals, 15 (4.7%) had stopped their urology practice at the private
hospital, but 11 of the 15 had continued to practice at the public hospital.

Of the urologist respondents, 31 (8.6%) were aged 60 years and older. Of these respondents, 15 worked in
a private hospital only, 15 worked in both private and public hospitals, and one respondent did not
complete the questionnaire except for demographic and COVID-19 related section. Among the 15
respondents who worked at both types of hospital, only 8 completed the private hospital section. Thus,
we had data on a total of 15 and 23 respondents who worked in public and private hospitals, respectively.
Only one had stopped all practice activities during the COVID-19 period.

Indonesia has six urology centres, each of which has a liated hospitals where residents undergo
rotation. However, during COVID-19 period, all centres called resident back from the a liated hospitals,
except Bandung urology center in West Java Province, which placed 9 of their residents in an a liated
hospital. Resident’s shifts are divided into hospital and working from home in all urology centres, except
for seven residents at a liated hospital shift due to lack of medical personnel. Moreover, educational
activities for urology residents were held using web-based video conference in all centres during the
COVID-19 epidemic.
Outpatient service
The number of patients before the COVID-19 epidemic and practice pattern to adjust to the epidemic
situation in outpatient clinics are shown in Figs. 2(a) and (b). Among respondents aged 60 years and
older, most still held face-to-face consultations at both public (86.7%) and private (73.9%) hospitals, with
only 33.3% and 26.1%, respectively, using teleconsultation.

Several measures had been taken to prevent COVID-19 transmission among patients in public and private
hospital outpatient clinics, including triage for patients with history of respiratory tract symptoms (72.1%
and 66.7%) and temperature screening (81.7% and 73.8) before entering the consultation room, requiring
patients to use face masks (95% and 81.3%,), and referring patients with suspected COVID-19 to other
departments (73.3% and 65.8%). One public hospital had built a glass barrier between doctors and
patients within the consultation room.

Surgery service
During the COVID-19 period, surgery, particularly elective surgery, is changing. The number of elective
surgery cases before the COVID-19 pandemic and its adjustment during the pandemic can be seen in
Fig. 2(c) and (d). Among respondents aged 60 years and older, 33.3% had stopped all elective surgeries.

Amongst urologists who continued to conduct elective surgeries, most conducted COVID-19 screening as
part of elective surgery preoperative preparation (74.6% and 81.7% at public and private hospitals,
respectively). Practices of urologists towards performing surgery on patients with COVID-19-related
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symptoms and patients who would require post-operative intensive care unit (ICU) care are shown in
Figs. 2(e) and (f). More than 50% of the urologists who continued to conduct elective surgery had never
performed laparoscopic surgery in their practice. However, of those who had previously performed
laparoscopic surgery, the majority (95.3% at public hospitals and 97.1% at private hospitals) did not
continue to perform laparoscopic procedures during the COVID-19 pandemic. Measures that had been
taken to prevent SARS-CoV-2 transmission in public or private hospitals, included reducing the number of
operating rooms (ORs), reducing the number of staff (59.5% and 63.9%, respectively), and not rotating
staff in the OR during surgery (26.6% and 33.6%). A small proportion of respondents (1.2%) had cancelled
surgery that required general anaesthesia (GA) or had entered the OR after the intubation was completed
by the anaesthesiologist.

When treating patients who required emergency surgery, most urologists (80.7% and 84.3% at public and
private hospitals, respectively) treated patients as COVID-19 positive. Other responses towards this
particular situation were to assess the patient’s COVID-19 status but to conduct the surgery without any
special precautions (14.5% and 12.2%).

Use of personal protective equipment

The use of PPE used by urologists and urology residents at public and private hospitals and its provision
by the hospitals is shown in Fig. 2(g).

Selection and prioritisation of surgery

The Urologists’ and urology residents’ opinions regarding selection and prioritisation of surgery is shown
in Fig. 3.

Other COVID-19 Impacts

Of the urologists and urology residents, 8.3% and 17.5% respectively, reported that they had treated
patients with suspected COVID-19, and 9.1% of urologists and 16.6% of urology residents reported that
they had treated patients without knowing their COVID-19 status and later discovered that they patients
had been positive.

Both urologists (84%) and urology residents (85.7%) stated that they were concerned about contracting
SARS-CoV-2 infection in their workplace.

Discussion
The COVID-19 pandemic is providing a major challenge for modern medicine in 2020. It has changed
many aspects of medical services, with urology being no exception, and has forced medical providers to
adapt their approach towards patient care, including outpatient care, inpatient care, and surgery
services.16,17 This study investigated the impact of the COVID-19 pandemic on urology daily practice in
Indonesia by means of a web-based questionnaire survey. This study had a 76% and 100% response rate

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for urologists and urology residents, respectively, which is considered a very high response rate.18
Moreover, it was found that less than 10% of the questions in each section were incomplete.

Two urologists and ve urology residents reported having contracted COVID-19. This suggests that
urology residents were more likely than urologists to contract COVID-19. Residents are often on the front
line of medical services, thus, extra precaution, particularly proper use of PPE, is a necessity. Among the
9.5% urologists and 27% urology residents who had been designated as a suspected case of COVID-19,
only 60% of the urologists and 62.7% urology residents had been quarantined or undergone self-isolation.
The reason behind this could not be determined from the responses. However, this should be investigated
because all suspected cases supposed to undergo quarantine to stop the spread of the virus.

As of 5 May 2020, there had been a total of 12,071 con rmed cases of COVID-19 in Indonesia. However,
only 88,924 people have been tested out of a population of more than 266 million (approximately 0.33
test per 1,000 people).19,20 This testing rate is lower than in other counties in the region, such as
Singapore (21.1 tests per 1,000 people), South Korea (12.49 tests per 1,000 people), Malaysia (6.59 tests
per 1,000 people) and India (0.86 tests per 1,000 people).21 This is why the number of COVID-19 cases in
Indonesia is considered to be the “tip of the iceberg”. To overcome this limitation, Indonesia’s Ministry of
Health has strati ed suspected cases of COVID-19 into PIM and PUS.

In Singapore, interhospital movement of health providers is forbidden, thus all residents have to stay at
an a liated hospital for the full rotation. In Indonesia, however, the majority of urology center asked for
all their residents to return from a liated hospitals.22 This might have been a good decision since lack of
shift rotation between residents and reduced working time provide residents with more time to rest. The
questionnaire did not ask urology residents speci cally regarding the impact of the COVID-19 pandemic
on their training. However, since all the surgery and outpatient clinics were greatly reduced, the effect on
their training is likely to be similar to the effect on Italian urology residents that 81.1% and 62.1% of them
experienced more than 80% decreased in both clinical and surgical activities, respectively .23

In reporting the results, we speci cally highlighted the responses of urologists aged 60 years and older
because of the more severe clinical manifestations and higher case fatality rate among people over the
age of 60 years.24,25 However, we found that the practice pattern of urologists aged 60 years and older
during the COVID-19 pandemic was similar to that of the respondents overall.

Indonesian urologists have a chance to practice in public and private hospitals and most of them have
practices in both public and private hospitals. There might be different pattern of practice between public
and private hospitals. However, it seems that the pandemic has had a similar effect on the outpatient
clinic services and elective surgery services of both hospital types.

IUA, as an organization accommodating all Indonesian urologists, has published recommendations for
urologists during the COVID-19 pandemic. These recommendations cover outpatient clinics, surgery
services, and PPE use.26 For outpatient services, this guidance recommend teleconsultation and

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restricting the number of patient consultations. Most urologists had already complied with the
recommendation to restrict the number of patients, but face-to-face consultation remained the primary
consultation method for outpatient services. Even though telemedicine is being developed and the
Indonesia government had been proactive by providing national policy support and for the development
of telemedicine, telemedicine is still unpopular among urologists of whom less than one quarter have
used telemedicine.27,28

According to IUA recommendations, all elective surgeries should be postponed in order to increase the
availability of healthcare workers, ICU beds, and inpatient rooms, in addition to preventing transmission
of SARS-CoV-2.26 However, only one-third of respondents stopped elective surgery, while most urologists
reduced their elective surgery activity by more than two-thirds of cases. In line with IUA recommendations,
most urologists conducted COVID-19 screening for patients undergoing elective surgery. Moreover, more
than two-thirds of urologists cancelled elective surgery requiring post-operative ICU care and about 30%
continued with planned elective surgery only if there was a risk of disease progression. The IUA guidance
recommends that it should be assumed that all patients undergoing surgery have COVID-19 unless
proven otherwise.26

Most respondents who regularly do the laparoscopic surgery had temporarily abandoned this procedure.
Even though it hasn’t been proven that COVID-19 could be transmitted via laparoscopic surgical smoke, it
should be avoided since several viruses, such as hepatitis B, human papillomaviruses, and HIV have a
potential for laparoscopic transmission and SARS-CoV-2 might have similar properties.22

In addition to emergency surgery, there are several urological procedures which are recommended to be
done due to risk of disease progression. IUA recommends that procedures for patients with severe
disease should to not be deferred, including surgery for muscle invasive bladder cancer or in situ bladder
cancer, testicular tumours, cT3 + kidney tumours, high-risk prostate cancer which cannot be treated by
radiation therapy, upper tract urothelial tumours, adrenal cortical carcinoma, and penile tumours. This
recommendation is in line with article written by Campi et al.29 which discusses the prioritisation of
urological surgery in Italy during the COVID-19 pandemic. Moreover, this recommendation is also in line
with respondents’ assessments of surgery priorities.

Surgical mask, face shields, medical gloves, and surgical cap were well utilized and provided by the
hospital. This should be su cient to protect healthcare workers in outpatient settings and inpatient
settings without patients with suspected or con rmed COVID-19 based on IUA recommendations.
However, medical gown availability appeared to be more limited among urology residents than among
urologists. This study also revealed a shortage of N95 masks among urologist and urology resident in
public hospitals. N95 masks are recommended for use in the care of patients with suspected or
con rmed COVID-19. Therefore, this shortage of equipment needs to be addressed.

Conclusion

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Even though this study has limitation such as incompleteness of data which could bias the result, it had
a high response rate and provides a picture of the impact of COVID-19 on urology practices in Indonesia.
This survey revealed that the COVID-19 pandemic has had a major impact on urology practice in
Indonesia for both practicing urologists and urology residents.

Abbreviations
COVID-19
Coronavirus disease 2019
ICU
Intensive care unit
IUA
Indonesian Urology Association
PCR
Polymerase chain reaction
PIM
Person-in-monitoring
PPE
Personal protective equipment
PUS
Patient under surveillance

Declarations
Ethics Approval and Consent to Participate

Implied consent was obtained from study’s participant since participant’s con dentiality was promised,
the participant had a choice to be anonymous (used speci c code, instead of his name) and the
participant also had a choice to participate or not in this study. Therefore, return of questionnaire was
considered as active consent to participate in this study. Moreover, this study was approved by the
Faculty of Medicine, Universitas Indonesia and Cipto Mangunkusumo Hospital ethical committee.

Consent for Publication

Not applicable

Availability of Data and Materials

Datasets are available from corresponding author upon reasonable request

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Competing Interests

All authors declare that there is no con ict of interest to disclose regarding the publication of this
manuscript

Funding

No fund was available for the current work

Author Contributions

NR and PB provided the idea to conduct this study. NR, PB, DP and FR constructed questionnaire. NR and
PB directed the manuscript construction. FR distributed the questionnaire and collected the data. DP and
FR wrote the manuscript. NR and PB reviewed the manuscript. All authors approved the nal version of
the manuscript.

Acknowledgements

We would like to express great appreciation for Mrs. Apitya Paskarini for helping distribute the e-
questionnaire via email and Dr. Ario Baskoro for helping reconstruct this study’s gures. We also wish to
acknowledge all Indonesia’s head of urology program and their chief of resident for helping gain 100%
response rate from all urology resident in Indonesia.

References
1. Li Q, Guan X, Wu P, Wang X, Zhou L, Tong Y, et al. Early transmission dynamics in Wuhan, China, of
novel Coronavirus–infected pneumonia. N Engl J Med. 2020;382:1199–207.
2. WHO. Coronavirus disease (COVID-19) pandemic. https://www.who.int/emergencies/diseases/novel-
coronavirus-2019. Accessed 5 April 2020.
3. Kementerian Kesehatan Republik Indonesia. Dashboard data kasus COVID-19 di Indonesia.
https://www.kemkes.go.id/article/view/20031900002/Dashboard-Data-Kasus-COVID-19-di-
Indonesia.html. Accessed 2 May 2020.
4. Chan JFW, Kok KH, Zhu Z, Chu H, To KKW, Yuan S, et al. Genomic characterization of the 2019 novel
human-pathogenic coronavirus isolated from a patient with atypical pneumonia after visiting
Wuhan. Emerg Microbes Infect. 2020;9:221–36.

Page 12/19
 5. Chu DKW, Pan Y, Cheng SMS, Hui KPY, Krishnan P, Liu Y, et al. Molecular diagnosis of a novel
Coronavirus (2019-nCoV) causing an outbreak of pneumonia. Clin Chem. 2020;555:549–55.
6. Huang C, Wang Y, Li X, Ren L, Zhao J, Hu Y, et al. Clinical features of patients infected with 2019
novel Coronavirus in Wuhan, China. Lancet. 2020;395:497–506.
7. Rothan HA, Byrareddy SN. The epidemiology and pathogenesis of coronavirus disease (COVID-19)
outbreak. J Autoimmun. 2020. doi:10.1016/j.jaut.2020.102433.
8. Lu S, Lin J, Zhang Z, Xiao L, Jiang Z, Chen J, et al. Alert for non-respiratory symptoms of Coronavirus
Disease 2019 (COVID-19) patients in epidemic period: a case report of familial cluster with three
asymptomatic COVID-19 patients. J Med Virol. 2020;2019:0–3.
9. Hu Z, Song C, Xu C, Jin G, Chen Y, Xu X, et al. Clinical characteristics of 24 asymptomatic infections
with COVID-19 screened among close contacts in Nanjing, China. Sci China Life Sci. 2020;63:706–
11.
10. World Health Organization. Infection prevention and control during health care when COVID-19 is
suspected. https://www.who.int/publications-detail/infection-prevention-and-control-during-health-
care-when-novel-coronavirus-(ncov)-infection-is-suspected-20200125. Accessed 26 May 2020.
11. European Centre for Disease Prevention and Control. Infection prevention and control for COVID-19 in
healthcare setting - rst update. 12. March 2020.
https://www.ecdc.europa.eu/sites/default/ les/documents/COVID-19-infection-prevention-and-
control-healthcare-settings-march-2020.pdf. Accessed 26 May 2020.
12. Royal College of Surgeons. Good practice for surgeons and surgical teams.
https://www.rcseng.ac.uk/standards-and-research/standards-and-guidance/good-practice-
guides/coronavirus/. Accessed 26 May 2020.
13. Gravas S, Bolton D, Gomez R, Klotz L, Kulkarni S, Tanguay S, et al. Impact of COVID-19 on urology
practice: a global perspective and snapshot analysis. J Clin Med. 2020;9(6):1730.
14. Gravas S, Fournier G, Oya M, Summerton D, Mario R, Chlosta P, et al. Prioritising urological surgery in
the COVID-19 era: a global re ection on guidelines. Eur Urol Focus. 2020.
doi:10.1016/j.euf.2020.06.006.
15. Isbaniah F, Kusumowardhani D, Sitompul D, Susilo A, Wihastuti R, Setyawaty V, et al. Pedoman
pencegahan dan pengendalian coronavirus disease (COVID-19). Kementrian Kesehatan Republik
Indonesia. https://corona.ntbprov.go.id/storage/dokumen/pedoman-covid-19.pdf. Accessed 26 May
2020.
16. Dzieciatkowski T, Szarpak L, Filipiak KJ, Jaguszewski M, Ladny JR, Smereka J. COVID-19 challenge
for modern medicine. Cardiol J. 2020. doi:10.5603/CJ.a2020.0055.
17. Ficarra V, Novara G, Abrate A, Bartoletti R, Crestani A, De Nunzio C, et al. Urology practice during
COVID-19 pandemic. Minerva Urol Nefrol. 2020. doi:10.23736/S0393-2249.20.03846-1.
18. Fincham JE. Response rates and responsiveness for surveys, standards, and the Journal. Am J
Pharm Educ. 2008;72(2):43.

Page 13/19
19. Badan Pusat Statistik. Indikator strategis nasional. https://www.bps.go.id/QuickMap?
id=0000000000. Accessed 7 May 2020.
20. Kementerian Kesehatan Republik Indonesia. Situasi terkini perkembangan Coronavirus Disease
(COVID-19). https://covid19.kemkes.go.id/situasi-infeksi-emerging/info-corona-virus/situasi-terkini-
perkembangan-coronavirus-disease-covid-19-6-mei-2020/#.XrQali-cZ0t. Accessed 7 May 2020.
21. Our World in Data. Total COVID-19 tests per 1,000 people. https://ourworldindata.org/grapher/full-
list-cumulative-total-tests-per-thousand?
country=IND+IDN+ITA+ZAF+KOR+USA+DNK+NZL+CAN+MYS+SGP. Accessed 7 May 2020.
22. Puliatti S, Eissa A, Eissa R, Amato M, Mazzone E, Dell’Oglio P, et al. COVID-19 and urology: a
comprehensive review of the literature. BJU Int. 2020. doi:10.1111/bju.15071.
23. Amparore D, Claps F, Cacciamani GE, Esperto F, Fiori C, Liguori G, et al. Impact of the COVID-19
pandemic on urology residency training in Italy. Minerva Urol Nefrol. 2020. doi:10.23736/S0393-
2249.20.03868-0.
24. Bialek S, Boundy E, Bowen V, Chow N, Cohn A, Dowling N, et al. Severe outcomes among patients
with coronavirus disease 2019 (COVID-19) - United States, February 12-march 16, 2020. Morb Mortal
Wkly Rep. 2020;69:343–6.
25. Liu Y, Mao B, Liang S, Yang J, Lu H, Chai Y, et al. Association between age and clinical characteristics
and outcomes of Coronavirus Disease 2019. Eur Respir J. 2020. doi:10.1183/13993003.01112-2020.
26. Rasyid N, Atmoko W, Daryanto B, Wahyudi I, Hamid ARAH. Rekomendasi pelayanan urologi terkait
COVID-19. 1st eds. Rasyid N, Atmoko W, Daryanto B, Wahyudi I, Hamid ARAH, editors. Jakarta: Ikatan
Ahli Urologi Indonesia; 2020.
27. Marcelo A, Ganesh J, Mohan J, Kadam DB, Ratta BS, Kulatunga G, et al. Governance and
management of national Telehealth programs in Asia. Stud Health Technol Inform. 2015;209:95–
101.
28. Varghese S, Scott RE. Categorizing the Telehealth policy response of countries and their implications
for complementarity of Telehealth policy. Telemed J e-Health. 2004;10:61–9.
29. Campi R, Amparore D, Capitanio U, Checcucci E, Salonia A, Fiori C, et al. Assessing the burden of
nondeferrable major uro-oncologic surgery to guide prioritisation strategies during the COVID-19
pandemic: insight from three Italian high-volume referral centres. Eur Urol. 2020;78:11–5.

Figures

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Figure 1

Respondent Distribution and Province COVID-19 Prevalence Map.3 (Template of Indonesia’s map was
taken from www.freepik.com).

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Figure 2

Urologist practice patterns and PPE use: (a) number of patients in outpatient clinic per day before the
COVID-19 period, (b) number of elective surgery cases per week before the COVID-19 period, (c) pattern of
outpatient clinic practice during the COVID-19 period, (d) adjustment of elective surgery cases during the
COVID-19 period, (e) elective surgery in patients with COVID-19-related symptoms, (f) elective surgery in
patients requiring intensive care unit (ICU) care, and (g) PPE used by urologists and urology residents and
its provision by the hospitals.

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Figure 3

Selection and prioritisation of surgery: (a) urologists’ surgery selection, (b) urology residents’ opinions
towards surgery selection, (c) urologist’s assessment of surgery priorities, and (d) urology residents’
opinions of surgery priorities

Supplementary Files
This is a list of supplementary les associated with this preprint. Click to download.

QuestionnaireEnglishVersion.pdf
STROBEchecklist.doc

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