INTRODUCTION COVID-19 in Washington State has led to unprecedented challenges within the Urologic community as physicians work to provide care that is safe for patients and staff. In order to conserve personal protective equipment (PPE) and to ensure hospital capacity for COVID-19 infected patients, Washington State Governor Jay Inslee directed that elective surgical procedures should be suspended on March 19, 2020 (1). However, non-elective Urologic care still needed to be provided. Preventing transmission of COVID-19 has been of paramount concern during the pandemic. Procedural care is at particularly high risk with its associated aerosol-generating procedures: intubation and extubation (2). Patients cannot be screened for infection solely based on symptoms, as a significant number are asymptomatic (3, 4), and many carriers never develop symptoms(5). Providing fit-tested N95 masks to all procedural staff is not currently feasible given the international shortage of PPE (6). Furthermore, pre-test probability of infection is difficult to estimate as our community's COVID-19 burden has not been established, and studies have demonstrated significant geographic variability within the United States (7, 8). Further complicating the picture are the wide variety of available testing modalities with a range of sensitivity, specificity, and negative and positive predictive values. The majority of these have been FDA approved under emergency use authorization (9). The harm in suspending Urologic care to the community is significant. Increased surgical waiting time (SWT) for T3 renal masses has been associated with decreased overall survival (10), and a delay in bladder cancer treatment has been demonstrated to lead to worse prognosis and higher pathologic stage (11). Based on Organ Procurement and Transplantation Network Data as of May 1, 2020 there has been nearly a 50% decrease in the number of kidney transplants performed in mid-March compared to mid-April, impacting a pre-existing shortage in available organs (12). Delayed relief of ureteral obstruction is associated with long-term renal dysfunction (13). Finally, the psychological impact of a delay in surgical care cannot be underestimated, affecting patient anxiety level and general health perceptions (14). In order to safely provide care for those who may be harmed by a treatment delay, on April 1st, 2020 Virginia Mason Medical Center committed to screen all patients prior to any surgical care. This implementation appears to be an effective measure to protect patients and staff, with no known COVID-19 cases in perioperative staff since the advent of screening. The primary objective of this study was to evaluate the impact of pre-operative COVID-19 screening on our ability to provide Urologic care. This was measured using Urologic surgical volume during an interval when discretionary surgery was suspended. MATERIALS AND METHODS Testing: Effective April 1, 2020 all pre-procedural patients were tested for COVID-19. Testing occurred within 48 hours prior to the scheduled intervention or at the time of hospital admission. A nasopharyngeal swab specimen was collected and processed using the Abbott RealTime SARS-CoV-2 assay. Mid-turbinate testing was substituted for nasopharyngeal swabs on May 3, 2020 in accordance with expanded CDC sampling guidelines (15). Patients who screened positive for COVID-19 were rescheduled to a later date. If medically stable, they were discharged home, and rescheduled for surgery following two subsequent negative repeat screening tests. In emergent situations, patients were either screened with a rapid ePLEX SARS-CoV-2 test or their procedure was performed in a specially engineered negative air pressure “COVID pod,” utilizing Powered Air-Purifying Respirators or fitted N95 face masks and eye protection. PPE for patients who tested negative for COVID-19 included standard surgical masks and protective eye shields. Stratification: All cases were triaged into one of five tiers: Emergent, Urgent, Planned Procedure level 1, Planned Procedure level 2, and Discretionary Procedure (Table-1). Proposed procedures were reviewed by an independent multidisciplinary committee to ensure that purely discretionary procedures (defined as a delay in performing the intervention would not result in harm to the patient) were not performed during the March 19 to May 18, 2020 prohibition period. Table 1 Triage levels used to determine case urgency during the COVID-19 pandemic with corresponding urologic procedures (non-exhaustive list). Triage Level Example of Procedures Emergent Fournier's gangrene debridement, decompression for obstructive pyelonephritis Urgent Decompression of symptomatic nephrolithiasis, cystoscopic fulguration for active bleeding Planned Procedure Level 1 Transurethral resection of high-grade bladder tumor Planned Procedure Level 2 Radical prostatectomy for high-risk prostate cancer, deceased donor renal transplant Discretionary Inflatable penile prosthesis insertion, mid-urethral sling Data Collection and Analysis Data regarding Urologic operative volume was collected retrospectively. Only procedural care based in the operating room was included in the analysis. Comparison of surgical volumes was performed between baseline [one year prior to the COVID-19 pandemic (March 19-May 6, 2019)], pre-intervention (March 19-March 31, 2020), and post-intervention (April 1-May 6, 2020) time periods. All statistical analyses were 2-sided, and significance was defined as p T1a renal neoplasms and bladder neoplasms (21). This approach limits unnecessary surgery during the COVID-19 pandemic. Although case volumes did increase in this study, expansion was done with the clear objective of performing procedures to manage acute disease processes, prevent harm to our patients, limit COVID-19 exposure, and conserve PPE. As the PPE shortage is relieved and emphasis changes, this study provides a model for expansion of a Urologic practice at a time when many institutions are resuming elective surgery (22). There are several weaknesses in this study: First, it was performed in a single institution. Second, the COVID-19 pandemic is rapidly evolving. Although screening facilitates appropriate and responsible assessment of patients prior to proceeding with care, it is unclear if the same strategy will be effective as the disease prevalence changes. Finally, our community currently has a relatively low penetrance of COVID-19. Applicability to regions with far greater burden have yet to be proven. CONCLUSIONS We believe that pre-procedural COVID-19 testing is a scalable intervention that will provide a means to safely reimplement care for the Urologic community. Eventually, Urologic surgical volume will need to expand nationwide in the setting of the ongoing COVID-19 pandemic and limited PPE. Universal COVID-19 screening of pre-operative patients represents a viable means to meet the needs of our patients.