Widespread cancellation or postponement of elective surgery and prioritization according to an emergency/
urgency principle have been the main features of the early reaction of surgeons to the COVID-19 pandemic [1]. Functional urology surgeries were mostly considered elective and in the low/intermediate group of priority [2]. In line with the dynamics of the pandemic in Italy and the corresponding trend in restrictive measures issued by the authorities, functional surgeries cancellation rates reached a peak in the month of April 2020, and trends toward a progressive return to pre‐COVID surgical activity have been noticed from May onwards [1]. However, patients' fear of visiting hospitals, especially those receiving COVID-19 patients, has been noticed as an unmeasured barrier to the return to normal levels of activity in the field of elective urological surgery, causing patients to postpone or decline their procedure [3]. We aimed to assess the impact of this phenomenon in our male urinary incontinence (MUI) tertiary referral centre, located in an urban academic hospital with a COVID facility, after the first year of COVID-19 pandemic.

We retrospectively reviewed our data of patients scheduled for MUI surgery from July 1, 2020, when we started to return to the pre-pandemic activity, to March 30, 2021 (study period: 9 months). Percentages of patients (overall and per procedure) operated on and of those that postponed or definitely refused the procedure were calculated. MUI procedures at our centre consisted of the implantation of retrourethral transobturator fixed slings (RTS) or artificial urinary sphincter (AUS). Both primary and re-do/salvage procedures were included. Data were compared with those of the same, pre-pandemic timeframe from June 1, 2019, to February 30, 2020 (control period). Time trend, reasons, and risk factors for deferring surgery were also assessed. MUI severity, waiting time, age, Charlson comorbidity index, incontinence duration, educational level, and geographical distance were included in the univariate risk factors analysis.

Overall, 32 patients (11 AUS and 21 RTS) declined the scheduled date for surgery during the study period; of those, 28 (9 AUS and 19 RTS) requested just a surgery postponement and 4 (2 AUS and 2 RTS) definitely refused the operation. Nineteen-nine (10 AUS, 9 RTS) out of 47 called patients (40.4%) were operated on during the study period, versus 30 (11 AUS, 19 RTS) out of 34 (88.2%) during the control period (2 p<.000). Fifty percent of all patients that were offered AUS implantation were finally operated on, versus 33.3% of those scheduled for RTS (2 p=.25); the same figures during the control period were 91.7% (2 p=.016) and 86.4% (2 p=.000). The time trend saw an increase of patients declining surgery during the second pandemic peak. Fear of getting infected by Sars-Cov-2 was the most frequently given reason (87.5%) for declining surgery during the study period; receiving the vaccination for COVID-19 close to the planned surgery date was another COVID-related reason. At univariate analysis, lower incontinence severity (U-test p<.000) and shorter waiting time (U-test p<.000) were significantly associated with surgery refusal/postponement.

At our tertiary incontinence surgery centre, patients deferring surgery for MUI has been a significant organizational trouble that made it difficult to effectively recover the accumulated surgical backlog due to COVID-19 first wave. About 60% of called patients declined MUI surgery during the last 9 months, compared to only 12% of the pre-pandemic period. This patients’ behavior was mainly due to patients’ fear of contracting coronavirus during the hospitalization. The most relevant post-COVID increase in the proportion of patients declining surgery was observed for RTS procedures and for patients with mild-to-moderate incontinence and shorter pre-procedure waiting time, indicating that for these patients COVID-19-related anxiety overcomes suffering due to incontinence.

COVID-19-related anxiety significantly affects patients' propensity to undergo MUI surgery and needs to be carefully addressed in all patients scheduled for surgical treatment of urological nonlife-threatening conditions which already require an accurate risk-benefit balance evaluation. Setting COVID-free patients’ pathways and healthcare facilities, shortening hospitalization as much as possible, together with a shared decision-making process and case‐by‐case discussion taking into account local resources and pandemic situation as well, may be effective strategies to manage this phenomenon.

Sacco E, Gandi C, Li Marzi V, Lamberti G, Serati M, Agro' EF, Soligo M; Italian Society of Urodynamics (SIUD). Extensive impact of COVID-19 pandemic on pelvic floor dysfunctions care: A nationwide interdisciplinary survey. Neurourol Urodyn. 2021 Feb;40(2):695-704.
Ribal MJ, Cornford P, Briganti A, et al. European Association of Urology Guidelines Office Rapid Reaction Group: an organisation-wide collaborative effort to adapt the European association of urology guidelines recommendations to the coronavirus disease 2019 era. Eur Urol. 2020;78(1):21-28
Ficarra V, Mucciardi G, Giannarini G. Re: Riccardo Campi, Daniele Amparore, Umberto Capitanio, et al. Assessing the burden of nondeferrable major uro-oncologic surgery to guide prioritization strategies during the COVID-19 pandemic: insights from three Italian high-volume referral centres. Eur Urol. 2020;78:11-15.