Since it was first reported in Wuhan, China, in December 2019, the novel coronavirus
has rapidly spread worldwide . To date it has infected more than 83 000 individuals,
and in the past week has made inroads into Europe , . On January 30, 2020, the
World Health Organization (WHO) declared the situation a public health emergency of
international concern and on February 11, 2020 named the disease COVID-19 .
Even before the first confirmed case in Singapore on January 23, 2020, authorities
including the Ministry of Health (MOH) raised national alert levels and implemented
wide-ranging, multiagency public health measures . By February 6, 2020 and up to
February 19, 2020, Singapore had the highest number of confirmed cases outside of
mainland China . The rate of contagious spread has since been overtaken by other
affected countries, and Singapore's sustained national efforts in early detection
and containment have been acknowledged by Harvard University  and the WHO .
Since the 2003 severe acute respiratory syndrome (SARS) outbreak that killed 33 people,
including healthcare workers, in Singapore, the nation has improved national outbreak
readiness by increasing training of infectious disease control personnel and improving
infrastructure. The National Centre for Infectious Disease (NCID), a purpose built
330-bed facility, officially opened in September 2019 . It is connected to Tan
Tock Seng Hospital (TTSH), one of the largest acute hospitals in Singapore (1700 beds
and 9000 staff) . NCID contains a screening centre (SC), isolation and cohort wards,
a high-level isolation unit, operating theatres, radiology suites, and laboratories.
As the forefront of the efforts in Singapore, the NCID SC operations required secondment
of TTSH staff, with urologists among those deployed. The SC assesses patients in terms
of travel or contact history , respiratory symptoms, fever, suspected or confirmed
COVID-19 status, and primary health care referrals. Emergency physicians oversee operations
in consultation with infectious disease physicians. At all times, a quarter of the
urology department complement of doctors was deployed to the SC, working 10-day rotations.
This correspondence shares our early experience, highlighting the impact on urology
practice, lessons learnt, and the role of urologists in outbreaks.
Impact on urology practice
TTSH reacted quickly to the COVID-19 outbreak and reduced inpatient and outpatient
services in preparation for a possible surge of COVID-19–related admissions and arranged
staff secondment to the NCID: internists were deployed to outbreak wards and surgeons
to the SC. The TTSH urology department implemented urgent measures to reduce specialist
clinics, outpatient procedures, and use of operating theatres.
Scheduled clinic appointments were screened. Patients with nonurgent conditions were
consulted via telephone and rescheduled for a minimum of 6 months later, with prescriptions
written for pickup or delivery. Clinics prioritised known or suspected malignancy,
obstructive uropathy, and immediate postoperative cases.
Likewise, outpatient procedures were stratified by urgency. Prostatic biopsies and
cystoscopy for patients at high risk of malignancy and extracorporeal shockwave lithotripsy
for obstructive ureteric calculi were allowed to proceed. All nonurgent procedures
Use of operating theatres was reduced from up to three to just one theatre daily.
Elective surgery cases were consulted via telephone and postponed, with priority reserved
for oncology and obstructive uropathy cases.
Ward rounds were reduced to essential personnel only, with all teaching rounds cancelled
and elective admissions minimised.
To minimise contagious spread, meetings were held via video conferencing. Journal
clubs, preoperative and postoperative discussions, and multidisciplinary meetings
were held in small groups in breakout rooms, with physical distancing maintained using
desktop and mobile-based applications.
In addition, real time location systems tracked staff movement in high-risk areas
in cases of positive COVID-19 contact.
Impact on residency training and undergraduate education
Escalation of the alert level mandated cessation of interhospital staff movement,
with residents who were rotating in other hospitals remaining there indefinitely.
Undergraduate clinical attachments were cancelled. Residency and undergraduate teaching
switched to online learning.
With national annual residency examinations scheduled for early 2020, disruption of
rotations, an increase in administrative load due to rescheduling of patients, and
SC responsibilities, residents were understandably anxious. Urology consultants acted
immediately to address this: they lobbied for postponement of examinations with the
MOH, ensured that every effort was devoted to providing support to staff at the SC,
and led by example in serving at the SC.
Our role as urologists and lessons learnt
Managing the initial stages of the COVID-19 outbreak has reinforced critical lessons.
Firstly, a key step is the maintenance of departmental emergency contingencies for
manpower cuts and diversion to facilitate quick responses to hospital and nationwide
emergencies. Similarly, contingencies should be made for education in exceptional
cases of disruption.
Secondly, the importance of administrative leadership in the organisation of clinics,
procedure lists, and use of operating theatres cannot be underestimated. Urgent patient
rescheduling was facilitated by existing protocols that register contact information
for all patients and triage them to the appropriate urology services. This outbreak
highlighted the importance of positive doctor-patient relationships and trust in making
such inconveniences more acceptable to patients.
Thirdly, senior staff serving at the SC were crucial for a balanced distribution of
senior and junior doctors and in boosting frontline staff morale. It was essential
to balance their leadership and administrative roles during the outbreak with their
service commitments at the SC, but having senior staff lead by example contributed
greatly to ensuring the remaining urology services ran smoothly, while motivating
junior staff at the SC.
Fourthly, the COVID-19 outbreak undoubtedly interrupted residency training and undergraduate
education. With the rigors of undergraduate medicine and residency, it is easy to
forget empathy, morality, and social responsibilities as a doctor. This outbreak was
taken as an opportunity to remind junior doctors of the humanitarian aspect of medicine,
as in the Hippocratic oath: “I will remember that I remain a member of society, with
special obligations to all my fellow human beings, those sound of mind and body as
well as the infirm” .
Lastly, embracing technology is important not just in clinical practice but also in
administration and communications. Interhospital and interdepartment meetings were
facilitated by existing electronic nationwide patient records with video-conferencing
using desktop and mobile applications, while education relied heavily on online learning.
As we deal with COVID-19 worldwide, this is a timely reminder to urologists of our
responsibilities as doctors first and foremost. COVID-19, infectious diseases, and
emergency medicine are far removed from a urologist’s specialised skill set, but we
should always remember the Hippocratic oath we swore and the importance of empathy
and servitude: “May I always act so as to preserve the finest traditions of my calling
and may I long experience the joy of healing those who seek my help” . Although
we have dedicated our careers to genitourinary surgery, in times of need, urologists
have a role to play in serving society and public health.
Conflicts of interest:
The authors have nothing to disclose.
CRediT authorship contribution statement
Ming-Chun Chan: Conceptualization, Writing - original draft. Sharon E.K. Yeo: Writing
- review & editing, Supervision. Yew-Lam Chong: . Yee-Mun Lee: Writing - review &