COVID-19 pandemic has caused profound changes in medical practice globally. Regular patient care has been dramatically affected since the focus of both the public and private health systems being shifted to the management of patients with COVID-19. Urinary incontinence (UI) is a major health problem with a tremendous negative impact on patients QoL.  Specialists and patients are becoming increasingly worried about the potential harm and impact on quality of life caused by deferring medical evaluation and treatment of female stress urinary incontinence (SUI) for a long time.
No studies reported on official numbers from a nationwide health system the decrease in procedures to treat SUI. To fill this gap we conducted this study to characterize the impact of one year of COVID-19 on the number of surgeries for female SUI from the perspective of the our national public health system.

This population-based retrospective cohort study focused on individuals who access care through the public health system of the Ministry of Health, which provides healthcare for approximately 70% of the country’s population.
This study was conducted with population- based data which includes hospital data collected by the national Hospital Information System (SIH).  Data for surgical procedures performed for female urinary incontinence in public health care system from 01/January 2019 to 31/December/2020 in each of the 27 states of the Federation were included. We identified all surgeries performed in the studied period using the procedure codes for surgeries for female SUI and the ICD-10 codes.The primary outcome was the overall number of surgeries for female SUI per state in 2019 and in 2020, and divided by the 27 Units of Federation.
All of these data are under public domain. As such, approval from an ethics committee was not required.

The results are described in the Table - Figure 1

Evaluating the impact of the COVID-19 in the number of surgeries for urinary incontinence, we observe a decrease of 53,2% in the whole country from 2019 to 2020. Considering the regions of Brazil, although some punctual differences in Units of Federation, we did not find differences in the impact of covid-19 on the number of surgeries for female urinary incontinence. All of them decrease the number of procedures. 
We find differences in the number of surgeries/1.000.000 habitants between the regions and units of federation, even before the Covid-19, being surgeries more common in South and southwest region than others. São Paulo, home to 21.86% of Brazilians, accounted for 32.1% of the procedures performed in the country. This disparity proves more evident when we see that the north and northeast regions performed 16.9% of surgeries (and 35,9% of population). This difference remains in 2020.

The first aspect to be discussed is that in Brazil we perform a few number of surgeries for female urinary incontinence, even before the COVID-19 pandemic. The Brazilian public healthcare system covers 70% of the population and in this group we find only 34,2 surgeries/1.000.000 habitants (3,0-94,3 according to the unity of federation). When compared with USA in 2003 (1) where they performed 571 surgeries/1.000.000 habitants and England in 2019 (2) with 400 surgeries/1.000.000 habitantes, our population is undertreated. The decrease of 53.2% of the surgical procedures for the treatment of female Urinary incontinence produces a big impact in the care of the Brazilian female patients with stress urinary incontinence. The expectation of treatment before COVID was under the international numbers, after COVID disruption we can expected that the undertreatment became even worse. 
The disparity in the number of surgeries by the different Units of Federation reflects the distribution of medical schools, distribution of resources for the healthcare system and regional characteristics. These data are important to evaluate and to propose actions in order to decrease these differences.
A key strength of this study was its population-based approach, based in a national database from two consecutive years, the first without COVID and the last under COVID disruption. The results provide insight into the current surgical management of female SUI in Brazil, in particular providing estimates of the major impact that COVID-19 had in this important health parameter. To the best of the authors’ knowledge, such data are presently lacking in the literature. 
This study has limitations inherent to its retrospective nature and the use of aggregate data. The unit of analysis was each of the federal units. The quality of data was also limited by the efficiency of government agencies in collecting and providing precise and comprehensive information. However, the large number of procedures analyzed (7.233) in a country with continental dimensions and 211 million inhabitants seems to make the findings robust and reliable.

This study provides new evidence on the surgical management of female SUI within the Brazilian public healthcare system. We have identified that women access to SUI surgery in Brazil for those patients is, at present, highly limited. In general, this study highlights the likelihood of a substantial unmet need for female SUI treatment in Brazil within public healthcare system, which was severely impacted by COVID-19. It also highlights the disparity between different states of the federation, even before the COVID-19. Future research is needed that focuses on the public and private healthcare system to better understand the current overall scenario of female SUI surgical treatment in Brazil.