Appendicular flap transposition in case of the left ureters defects

Introduction & Objectives: The frequency of involvement in the oncological process of the ureters in case of pelvis tumors ranges from 15 to 20%. The use of the appendix as a plastic material for the reconstruction of extended ureteral defects (EUD), including left-sided ones, remains debatable. The main goal of this study is evaluating the clinical and functional results after EUD repair using patchy transposition of the appendix. Material(s) and Method(s): Since August 2019 to June 2021, 8 laparoscopic surgeries were performed to replace the EUD using flap transposition of the appendix. Of these, 6 on the left (75%), 2 on the right (25%). 7 women (87.5%) and 1 man (12.5%) were operated on. Mean age 53+/-10.6 years. Average BMI 25.9 kg/m2. Etiology EUD: 25% radiotherapy (n2), 50% iatrogenic surgery (n4), 12.5% (n1) primary ureteral cancer, 12.5% (n1) non-Hodgkin's lymphoma. In all cases, the first stage was a wide mobilization of the ileocecal angle, the appendix was disconnected with a 45 mm hardware suture, in case of left-sided lesion, the appendix was moved isoperistaltically under the mesentery of the sigmoid colon to the left side after preliminary maximum mobilization of the process on the vascular pedicle in the form of a "triangle". All patients received a 7Fr ureteral stent. CT urography was performed on the 3rd, 7th, 11th days. Dynamic nephroscintigraphy was performed on the 90th day. Result(s): The average length of diastasis is 4.6+/-1.7 cm. The average length of the mobilized appendix was 8+/-1.8 cm. Replacement of the ureter with an appendix and a flap of the bladder according to the Demel method was performed in 1 case (12.5%), according to the Boari method in 1 case (12.5%), in 6 (75%) cases an anastomosis was formed according to the "end-to-end" type. the end". The average duration of the operation was 251+/-40.9 min, blood loss was 121+/-56.7 ml. Median removal of the ureteral stent was 36+/-18.28 days. Duration of hospital stay was 14+/-5.2 days. Median follow-up 10+/-5.3 months. Early complications (<30 days): 2 cases of urinary edema (Clavien-Dindo II), 2 cases of ipsilateral hydronephrosis (Clavien-Dindo I-II). Late complications (>30 days): 1 case of partial failure of ureterocystoanastomosis against the background of Sars-Cov-2 infection (Clavien-Dindo IIIa), 1 case of non-functioning left kidney (Clavien-Dindo IVa). Dynamic nephroscintigraphy was performed in 68.4% of patients, the average isotope accumulation time was 4.23+/-0.25 minutes, the duration of the half-life was 14.26+/-0.52 minutes. Conclusion(s): Flap transposition with the appendix is a technically difficult but possible option for extended ureteral strictures. However, various pathological processes that have developed against the background of previous treatment potentially increase the risk of developing repeated strictures or anastomotic leaks. Therefore, given the small sample of patients, further research on this issue is required.Copyright © 2023.

Finding an Answer for an Adolescent with Back Pain

Case report - Introduction: This is the case of an adolescent referred to rheumatology following 5 years of back pain. After years of trying a number of treatments without much success, the cause was found to be a previously undiagnosed urological pathology. The case highlights awareness of non-rheumatological causes and incidental findings which can redirect a patient towards more appropriate treatment and reduce the potential for long-term adverse health issues and anxiety. Case report - Case description: B was referred age 16 to rheumatology with a 5-year history of lower back pain. She had previously seen paediatricians with symptoms initially attributed to constipation due to intermittent straining and hard stool. However, constipation remedies had not relieved the pain which progressed gradually to a more persistent dull ache with impact on daily activities. Various analgesics (including paracetamol and non-steroidal anti-inflammatories), exercises and acupuncture had not helped. There was no history of recurrent urinary tract infections or symptom correlation with fluid intake, menstruation or bowel habit. No inflammatory features or connective tissue disease symptoms were noted and family history was unremarkable Clinical examination was normal apart from mild tenderness in the lumbar region. Rheumatoid factor was borderline positive (15 iu/mL) with the rest of blood tests normal including renal function, inflammatory markers (CRP, ESR), anti CCP and ANA. She had minimal microscopic haematuria without proteinuria. MRI spine in 2015 was normal. In view of her young age and symptoms affecting daily activities, STIR sequence spinal MRI was requested. This excluded any new or old inflammatory changes but incidentally identified a dilated left pelvi-calyceal system. Renal ultrasound confirmed a grossly hydronephrotic left kidney with hydroureter and minimal renal tissue suggesting longstanding obstruction. No calculi were seen. The patient was referred to urologists. Further investigations (including MRI abdomen) confirmed similar findings and a distal ureteric stricture. A MAG 3 renogram showed a normal right kidney but only 12% functioning of the left kidney. Urologists have advised surgery (removal of left kidney and ureter) which may relieve symptoms or a conservative non-surgical approach (continue analgesia, physiotherapy and monitoring). The patient and her family are relieved to have a possible cause identified and are considering the surgical option due to ongoing flank discomfort. Case report - Discussion: This was an interesting finding of hydroureter and hydronephrosis causing longstanding back pain presenting to rheumatologists. Until completion of the spondyloarthropathy protocol MRI (STIR images), aetiology had been unclear. Hydronephrosis and hydroureter has no specific age or racial predilection. Signs and symptoms may depend on whether obstruction is acute/chronic. Chronic cases may be asymptomatic or present as a dull discomfort (like this case). Some cases may only present in adulthood with pain precipitated by fluid intake. Blood tests may show impaired kidney function. Post-mortem studies suggest 50% of people have at least one renal abnormality (e.g., renal cysts, duplex ureters) with autopsy series incidence of hydronephrosis reported as 3.1%. Causes include anatomical abnormalities such as vesico-ureteric reflux, urethral strictures (usually present in childhood), calculi, benign prostatic hyperplasia, or intrapelvic neoplasms, pregnancy and infections (e.g., TB). Sudden onset unilateral renomegaly was reported in one case of primary Sjogren's with lymphocytic interstitial nephritis and positive Sjogren's autoantibodies. Our patient has no clinical or serological evidence of connective tissue disease. Minor pelvi-calyceal distension can occur as a normal finding in wellhydrated patients and pregnancy. However, significant hydronephrosis requires assessment to determine cause as it may affect long term renal function. Imaging via computed tomography, ultrasound and urograms can help guide further management. In this case the preceding cause and duration of pathology is unknown. Sterile, giant hydronephrosis treatment options include observation and ureteric stent or nephrostomy in patients unfit for surgery. Nephrectomy is advised for pain and recurrent infection in a non-functioning kidney. Complications may include bowel perforation, vascular injury and urine leakage. Both open and minimally invasive procedures have good reported outcomes. The COVID-19 pandemic and exams have affected timing of any elective procedures and the patient understands surgery may or may not offer complete symptom resolution. Case report - Key learning points: . Non-inflammatory causes of back pain should always be considered in cases of persistent back pain, particularly in young people to ascertain if there is a treatable cause . Hydronephrosis cases can be asymptomatic or present with vague, intermittent, non-specific abdominal symptoms with normal physical examination with or without haematuria. This can cause diagnostic uncertainty and delay referral to urology and appropriate renal investigations . Assessment of renal function (including MAG 3 renogram) is important to guide further management . Surgical interventions (pyeloplasty/nephrectomy) may ease symptoms long term but there is no guarantee of a successful outcome and operative risks need to be considered too . Left undiagnosed, potentially this patient could have had further disruption to daily activities and both physical and mental well being.

Impact of Delay in Surgical Intervention on Functional Outcomes in Children with Unilateral Ureteropelvic Junction Obstruction

Introduction &Objective: Uretero-pelvic junction obstruction (UPJO) is the most common cause of obstructive uropathy in children. However, the timing of surgical intervention is debatable and the effect of delayed surgical intervention is also not well-understood. For example, COVID-19 pandemic has led to institutional delays and surgical shutdowns in all medical fields worldwide. Therefore, we aimed to identify the effect of delay in surgical intervention on renal function in cases of of unilateral UPJO and factors that may affect it. Method(s): In a retrospective study, database of children who underwent pyeloplasty for unilateral UPJO in a tertiary center from January 2016 to October 2020 was reviewed. Patients who had a delay in pyeloplasty for more than 3 months from the time of diagnosis were identified. Patients for whom 3 renograms were performed at the time of surgical decision, immediately before surgery and within one year postoperatively were included in the study. Deterioration was defined as 5% or more decline in the split renal function (SRF) between 2 consecutive renograms. Patients were then categorized into 2 groups;group of preserved renal function (group 1) and group of deteriorated renal function (group 2) based on the difference in preoperative renograms. Both groups were compared regarding the preoperative and postoperative Antero-posterior diameter (APD), grading of hydronephrosis (HN), percent of change of HN, change in SRF and duration of delay in months. Result(s): A total of 46 children were included in the study;30 patients had preserved renal function (group 1), while 16 patients had significant deterioration of SRF (group 2). Group 2 showed higher percent increase of APD and more delay in the surgical intervention on univariate analysis, p value = 0.016 and 0.001, respectively (Table 1). On multivariate analysis these factors showed significant difference between both groups. However, other factors did not show any significant difference between the two groups. None of the patients who had surgery within 6 months showed functional deterioration. Conclusion(s): Delaying of surgical intervention for less than 6 months may not lead to functional deterioration. Moreover, worsening of HN might precede functional deterioration.

RAPIDLY PROGRESSIVE GLOMERULONEPHRITIS IN THE SETTING OF GRANULOMATOSIS WITH POLYANGIITIS AND COVID-19

SESSION TITLE: COVID-Related Critical Care Cases SESSION TYPE: Case Reports PRESENTED ON: 10/19/2022 11:15 am - 12:15 pm INTRODUCTION: We present a case of rapidly progressive glomerulonephritis in a patient with granulomatosis with polyangiitis and COVID-19 pneumonia. CASE PRESENTATION: A 72 year old man presented to the hospital with shortness of breath, fatigue, fevers, and malaise. Chest x-ray showed bilateral lower lobe infiltrates consistent with COVID-19 pneumonia and creatinine of 1.57, elevated from baseline of 1.30. He was diagnosed with COVID-19 pneumonia and admitted to the Intensive Care Unit due to acute hypoxic respiratory failure and worsening acute kidney injury. Past medical history was significant for granulomatosis with polyangiitis (GPA) with recurrent deep venous thromboses and splenic infarct. Warfarin was held due to supratherapeutic INR on admission. COVID-19 drug therapy was initiated, including baricitinib, remdesivir and decadron. Creatinine began to rise significantly and renal ultrasound was ordered but showed no hydronephrosis or acute abnormality of the kidneys. There was no improvement with administration of fluids, and hemodialysis was initiated due to worsening creatinine with a peak of 12.09 and a strong suspicion for rapidly progressive glomerulonephritis (RPGN) in the setting of GPA. High-dose steroid therapy was started and daily hemodialysis was continued. Patient required transfer to a tertiary care center for multifactorial shock where he continued to receive dialysis therapy. Patient eventually required mechanical ventilation and ultimately expired. DISCUSSION: GPA is an autoimmune small and medium vessel vasculitis most often associated with anti-neutrophil cytoplasmic antibodies (c-ANCA). Without treatment, GPA has a high mortality rate due to systemic vasculitis. Treatment of GPA includes immunosuppressive therapies like rituximab or cyclophosphamide. Environmental and infectious processes are thought to cause GPA. Viruses have also been shown to cause GPA with two such cases documented with SARS-CoV-2. Our case illustrates a patient with known previously GPA who developed RPGN in the setting of COVID-19. RPGN can lead to rapid loss of renal function in GPA and can be the initial presentation of the disease process. However, care must be taken as often the presentation of GPA lung sequela may mimic those of COVID-19, including dyspnea, hemoptysis, and radiographic changes. Obtaining ANCA autoantibodies as well as a urinalysis showing proteinuria can help distinguish GPA and guide clinical judgment in starting high-dose steroid therapy early in renal failure due to RPGN in the setting of COVID-19. CONCLUSIONS: COVID-19 in patients with GPA can trigger renal failure due to RPGN. Reference #1: Bressler MY, Pathak N, Cervellione K, et al. New Onset Granulomatosis with Polyangiitis Associated with COVID-19. Case Rep Dermatol Med. 2021. Reference #2: Hasan MR, Sakibuzzaman M, Tabassum T, Moosa SA. A Case of Granulomatosis with Polyangiitis (Wegener's Granulomatosis) Presenting with Rapidly Progressive Glomerulonephritis. Cureus. 2019. Reference #3: Lutalo PM, D'Cruz DP. Diagnosis and classification of granulomatosis with polyangiitis (aka Wegener's granulomatosis). J Autoimmun. 2014. DISCLOSURES: No relevant relationships by Kristin Davis No relevant relationships by Charles Peng

Abstract of 17th Congress of Pediatric Emergencies and Common Diseases

The proceedings contain 81 papers. The topics discussed include: anaphylaxis to COVID-19 vaccines;multisystem inflammatory syndrome in children (MIS-C): clinical manifestation, evaluation & diagnosis;clinical characteristics of children with COVID-19 complicated by acute kidney injury;a referral center experience;antenatal hydronephrosis;a myelodysplastic syndrome evolution;neonatal thrombosis and related risk factors;the biologics in multisystem inflammatory system in children;side effects and contraindications of COVID-19 vaccines;hematopoietic stem cell transplantation (HSCT) in children;epidemiology and pathophysiology of foreign bodies of the esophagus and gastrointestinal tract in children;and co-administration of COVID-19 vaccine and routine vaccines and influenza vaccine.

Peritoneal Rupture of Hematocolpos in Distal Vaginal Atresia

An adolescent girl with vaginal atresia, massive hematocolpos and bilateral hydroureteronephrosis presented with an acute abdomen secondary to spontaneous rupture of the hematocolpos into the cul-de-sac. Diagnosis, treatment, postoperative course and complications of this unique case are briefly summarized. Spontaneous rupture of hematocolpos into the abdominal cavity is an extremely rare manifestation of vaginal atresia. Tertiary care management, which involves a multidisciplinary team of experienced gynecologists, plastic surgeons, urosurgeons, and critical care physicians, is recommended for optimal management of these patients. Patient education is also crucial;regular follow-ups visits and strict adherence to the postoperative vaginal dilatation schedule can reduce risk of stenosis after vaginoplasty.

IMPLEMENTATION OF A SIMPLE CLINICAL PATHWAY INCREASES RELEVANCE OF INPATIENT CONSULTS FOR URINARY RETENTION

INTRODUCTION AND OBJECTIVE: Inpatient consultations are sometimes initiated in order to establish care without any acute need for specialist services. This creates additional expense for the health system while potentially delaying patient care and/or discharge. Urinary retention is often straightforward, requiring only bladder rest and medical optimization prior to trial of void in the outpatient setting for resolution. We sought to evaluate whether or not a simple decision tree could assist medical hospitalists in appropriately selecting patients requiring inpatient urologic management from those who can be safely directed to outpatient care. METHODS: Consults for urinary retention were identified based on billing data from July 2019 through June 2021. Male and female retention guideline policies were implemented to assist primary teams in determining if a patient's retention could be managed via simple algorithm, or were deemed complex and requiring of inpatient urologic evaluation. Consults were considered complex if associated with gross hematuria with clots, recent pelvic trauma, neurologic deficits/injury, new or worsening hydronephrosis, or acute kidney injury. Patients were grouped into a pre-intervention 8-month period of July 2019 through February 2020, which was compared to a post intervention 10-month period of September 2020 through June 2021. March to August 2020 were excluded due to COVID-19 hospital volume changes. Chi square analysis was performed. RESULTS: A total of 163 retention consults were placed over the 18 study months. In the pre-intervention period, urology consultation was only truly required in 27/80 (33.8%). After implementation of the pathway, this significantly increased to 47/83 (56.6%, p=0.003). Furthermore while the percentage of monthly consults requiring inpatient consultation increased in the post-intervention period, the overall total number of consults decreased from 10.0/month to 8.3/ month. CONCLUSIONS: Implementation of this urinary retention pathway increased the number of relevant inpatient consults while decreasing the number of simple retention consults. The net effect was a decrease in overall consults. This simple pathway may have identified more complex patients while reducing overutilization of specialist care.

Preference and perception of treatment choices between radiologists and urologists for treatment for urgent urinary obstruction – nephrostomy versus retrograde ureteric stent: European survey from YAU and ESUT Endourology groups

Introduction & Objectives: Urological emergencies related to urinary obstruction need Percutaneous Nephrostomy (PCN) or Retrograde Ureteric Stent (RUS). The choice of treatment is often debated between radiologists and urologists due to differences in perception for given scenarios and the skill set needed for these. We wanted to conduct a European survey to determine the preference of treatment in different clinical situations. Materials & Methods: A European survey was conducted via the EAU sections (YAU and ESUT) for preference and treatment choices between radiologists and urologists for using PCN or RUS or primary ureteroscopy (URS) in various clinical scenarios. Responders were asked to select urinary drainage for 3 clinical scenarios before and after reading evidence from literature on use of PCN or RUS. The scenarios were ureteric stone related – infected obstructed kidney (scenario 1), obese patient with pain and hydronephrosis (scenario 2) and solitary kidney with deranged renal function (scenario 3). Results: Of the responses (n=367), there were 15.4% (n=57) radiologists and 310 (84.5%) urologists. The choice of drainage for scenario 1,2 and 3 between urologists and radiologists pre- and post-evidence perusal are shown in Table 1. Regarding QoL, cost and radiation dose (Table 2), the perception was that Radiologists appear to consider JJ stents to provide a better QoL (p=0.0004) and more radiation exposure (p<0.0001) than Urologists. The perception in both groups was that stent was more expensive (p=0.652507). With COVID-19 pandemic, there was also a rise in the usage of local anaesthetic stent and URS procedures. (Table Presented) Conclusions: Choice of urinary drainage for urological emergencies is dependent on multiple factors, but prompt management is paramount. This survey has shown how urologists and radiologists both put patient safety at the forefront and their choice of treatment reflects their expertise in the given technique.

The development and application of a triage system for urolithiasis during COVID-19.

PURPOSE: To balance epidemic prevention with the therapeutic needs of patients with urolithiasis during the COVID-19 pandemic, we developed a triage system to guide medical staff in making priority decisions. METHODS: The study began with a review of the literature to propose a theoretical framework. Then, focus groups were assembled to develop, supplement, refine and form a consensus on the indications of the triage system. Finally, the system was implemented in the clinic. The validity and reliability of the system were tested by a content validity index and the interrater reliability kappa coefficient. Changes in patient characteristics and waiting time before and after the epidemic were compared. RESULTS: The theoretical framework was based on disease pathophysiology, including obstruction, infection, kidney dysfunction, and other symptoms. With this guide, a 28-item triage system with categories of T1-5 (low priority to urgent) was developed. The content validity index and the interrater reliability coefficient were 0.833 and 0.812, respectively. During clinical application, although the total number of patients remained steady, the proportion of T1 decreased significantly; even though the overall waiting time of patients did not change significantly, it increased for T1 and decreased for T2-4 in 2020 compared with 2019 (P < 0.05). CONCLUSION: This triage tool based on the dimensions of obstruction, infection, kidney dysfunction, and other symptoms has good psychometric properties and significant utility for prioritizing patients with urolithiasis during times of crisis. With this system, patients of moderate to high priority were treated promptly during the COVID-19 pandemic.

POS-139 AN ATYPICAL PRESENTATION OF DUAL-POSITIVE ANTI-MYELOPEROXIDASE AND ANTI-GLOMERULAR BASEMENT MEMBRANE ANTIBODIES VASCULITIS WITH PULMONARY-RENAL SYNDROME : A CASE REPORT

Introduction: Double-positive vasculitis with anti-polynuclear cytoplasm (ANCA) and anti-glomerular basement membrane (GBM) antibodies is a rare entity of systemic vasculitis defined by the presence of ANCA and anti-GBM antibodies. Methods: We report a rare case of pulmonary-renal syndrome with atypical clinical presentation. Results: A 52 year-old smoking man with a history of exposure to hydrocarbons and uretheral lithiasis, presented in April 2021 epigastralgia and vomiting. the investigations concluded to H.pylori gastritis and ulcer and he received a quadruple therapy. The kidney function was correct in April 2021. The evolution was marked by the persistence of symptoms and urine output had decreased for a few days. He was found to have renal dysfunction (serum creatinine: 2000 µmol/L). Abdominal CT scan without iodinated contrast injection showed severe hydronephrosis of the right pelvicalyceal system with cortical thinning and dilatation of the right ureter. The two kidneys had regular outlines seat multiple bilateral renal cysts with exophytic development. He had a nephrosomy with secondarily a right double-J stent with slight improvement of renal function. The patient presented then with acute respiratory distress.Testing for COVID-19: PCR and serology were negatives. Chest CT scan showed alveolar syndromeevoking pulmonary overload. No pneumopathy covid was shown. The evolution was marked by the non improvement by depletion and he developed hemoptic sputum and low-abundance epistaxis. The attitude was non-invasive ventilation and broad-spectrum antibiotics therapy. Control chest CT showed emphysematous lung with signs of fibrosis with bilateral subpleural nodules. A rereading of the scanner showed intraalveolar hemorrhage which has regressed on the imaging of the control. Based on these data, pneumo renal syndrome was suspected and a bronchoscopy was performed showing alveolar hemorrhage with 70% siderophageswith Gold score superior to 100. Anti-GBM and p-ANCA and antibodies were positive at a high titer. Electroneuromyogram was without anomaly. Kidney biopsy was not done because of the presence of multiple cysts. The patient received pulse methylprednisone for three days followed by oral prednisone and underwent eleven sessions of plasmapheresis. Intraveinous Cyclophosphamide has been started. He showed remarkable recovery as his lung fields cleared with negativity of GBM antibodies. Kidney function didn't improved and he remained dependent on dialysis. Conclusions: Our observation is exceptional since the clinical and radiological presentation of the patient was not that of a pulmonary-renal syndrome. The elements of this syndrome have in fact been masked by the obstacle on the urinary tract on one hand and the hypothesis of a covid19 pneumonia on the other hand in the face of the epidemiological context. Atypical feature of pulmonary renal syndrome should be kept in mind to avoid diagnostic and treatment delays. No conflict of interest

Tuberculosis

Tuberculosis (TB) is a communicable, airborne infectious disease caused by the bacterium Mycobacterium tuberculosis (MTB). A quarter of the world's population is infected with TB, affecting all age groups. Infection with MTB results in latent or active disease. Latent infection is associated with a 10% lifetime risk of developing active disease, but this is much higher in those with concurrent immunosuppression. Despite being both preventable and curable, TB remains the leading cause of global death from a single infectious agent. Active disease most commonly affects the lungs but can spread to cause extrapulmonary disease anywhere in the body. Over half of individuals in the UK now present with features of extrapulmonary TB, those with HIV being at particular risk. In all cases, obtaining samples for TB culture is absolutely vital. Standard treatment is with quadruple therapy for 6 months, extended in TB meningitis and often TB bone infection. Adjunctive corticosteroids have proven benefit in TB meningitis and TB pericarditis, and can be considered in other circumstances, such as paradoxical reactions to starting treatment in miliary TB. Despite recent gains in diagnosing and treating TB cases worldwide, the global COVID-19 pandemic is likely to have significantly affected recent progress.

The use of ct urography to diagnose upper tract urothelial carcinomas (UTUC);managing surgical resources during the CIVID-19 pandemic

Introduction: Upper tract urothelial carcinomas (UTUC) account for 5- 10% of urothelial malignancies. Rapid diagnosis is essential as 60% are invasive at diagnosis and confer poor prognoses. European Association of Urology (EAU) guidelines recommend CT urography (CTU) for initial diagnosis and staging of UTUCs. Diagnostic ureteroscopy (URS) is used second line where diagnosis is unclear. The COVID-19 pandemic has limited theatre access and may delay diagnosis of suspected UTUC. Our aim was to evaluate specific CTU findings in predicting UTUC to aid prompt diagnosis and risk stratification in a tertiary centre. Method: A retrospective analysis was performed on 122 patients who underwent CTU with diagnostic URS over two years from 2018-2019 for possible UTUC. Data including demographics, imaging and histology were collected from our electronic database. Results: 57 patients had confirmed UTUC, all had CT changes. CTU had an overall positive predictive value (PPV) of 45%. CT findings were divided into: hydronephrosis;filling defect/lesion;urothelial thickening;normal;or other. The PPV was highest for filling defects/lesions at 60%, hydronephrosis was 38%, urothelial thickening was 30%, and other was 33%. Of those with high-grade histology, 61% had evidence of filling defects/lesions and 24% had hydronephrosis. Conclusions: A specific CTU finding of filling defect/lesion in combination with cytology can aid diagnosis and risk stratification of UTUC. This may enable us to reduce use of diagnostic URS, as well as associated risks of intravesical seeding, necessary in the COVID-19 pandemic. With other CTU findings of hydronephrosis or urothelial thickening, a diagnostic URS may be required.

The impact of COVID-19 on surgical care delivery for patients with urinary stones

Introduction & Objective: During the COVID-19 pandemic, limits on elective surgical care were instituted by hospitals to preserve resources. Additionally, patients' desire to limit health care contact may impact surgical decision making.We aimed to understand how institutional pressures and patient preference affected the delivery, choice and outcome of ambulatory surgical care for urinary stone disease during the COVID-19 pandemic. Methods: Reducing Operative Complications from Kidney Stones (ROCKS) is a quality improvement initiative from the Michigan Urological Surgery Improvement Collaborative (MUSIC) that maintains a prospective clinical registry of ureteroscopy (URS) and shockwave lithotripsy (SWL) cases. Using this registry, we categorized all cases by time frame, defining July 1st - December 31st 2019 as preCOVID (PC), March 16th - June 15th 2020 as duringCOVID (DC) and June 16th - September 15th 2020 as afterCOVID (AC). Patients in each cohort were characterized across a range of sociodemographic and clinical factors. We assessed changes in procedure choice (URS vs SWL), procedure acuity (elective vs emergent), and outcomes (ED visit and hospitalization within 30 days of surgery). Results: 6375 cases were identified, 4513 URS and 1862 SWL. PC consisted of 3310 cases (2238 URS and 1072 SWL), DC consisted of 1141 cases (888 URS and 253 SWL) and AC consisted of 1924 cases (1387 URS and 537 SWL). A higher proportion of URS cases were performed DC compared to PC and AC (77.8% vs 67.6% vs 72.1%, p < 0.001, respectively). A higher percentage of emergent cases in DC compared to PC and AC (21.8% vs 13.7% vs 15.3%, p < 0.001, respectively). Significantly more cases in DC compared to PC and AC were prestented, had positive UA/urine culture, ureteral stones, had hydronephrosis, were stented and had longer stent dwell time. ED visits and unplanned hospitalizations were not significantly different. Conclusions: The COVID-19 pandemic resulted in a lower overall stone treatment rates and higher proportions of URS compared to SWL. Significantly more emergent cases for ureteral stones with positive UA/urine cultures and evidence of obstruction were performed duringCOVID with higher stent placement rates and longer stent dwell times. These data pointing towards preference for higher intensity or acuity cases without differences in unplanned healthcare encounters. (Table Presented).

Cross-sectional survey of patients awaiting nephrolithiasis surgery during the covid-19 pandemic onset: A multi-center study from the registry for stones of the kidney & ureter group

Introduction & Objective: The Coronavirus pandemic led to wide-spread reductions in surgical volume. Many patients were hesitant to undergo surgery, despite appropriate hospital precautions. Kidney stone patients pending surgical intervention have distinct risks associated with surgical delay including pain, infection, and loss of renal function. It is important to understand the risks of surgical delay during the pandemic and to better understand patient concerns and preferences for undergoing surgery. Methods: A prospective, multi-institutional patient survey during April and May 2020 was performed. Nephrolithiasis patients pending stone removal surgery including ureteroscopy, shockwave lithotripsy, percutaneous nephrolithotomy, and nephrectomy were interviewed at clinical encounters regarding their symptoms, unplanned clinical events, presence of nephrostomy tubes /double J stents, concerns and reassurances for coming to the hospital, and willingness to undergo surgery. The association of patient demographics, stone burden, renal function, stonerelated symptoms, and COVID risk factors with willingness to undergo surgery, and concerns for contracting COVID were examined. Results: 142 patients pending stone surgery completed surveys, with 66% willing to proceed with surgery, while 34% requested to delay. There was no statistical difference in patients willing versus unwilling to proceed with surgery, with regards to patient demographics, type of surgical procedure, stone burden, stonerelated symptoms, renal function compromise, presence of hydronephrosis, unplanned clinical events, or COVID risk factors. Those willing to proceed were more likely to have a ureteral stone (32% vs 15%, p = 0.03) or have a ureteral stent or nephrostomy tube in place (35% vs 6%, p < 0.01). Willingness to proceed with surgery was inversely correlated with COVID19 concerns. COVID19 concern was not impacted by age, sex, clinical site, distance to hospital, or COVID 19 risk factors. Conclusions: Kidney stone patients pending surgical treatment weremore willing to proceed with surgery based on the presence of a ureteral stone, upper urinary tract drainage tube, or low concern for COVID. Patient demographic, symptoms, kidney function, and other stone risk factors were not associated with willingness for surgery. Patients that are hesitant to proceed with surgery, despite appropriate hospital precautions should be educated appropriately regarding their risks with regards to COVID and nephrolithiasis.

Impact of Surgical Wait Time on Survival in Patients With Upper Urinary Tract Urothelial Carcinoma With Hydronephrosis.

BACKGROUND AND OBJECTIVES: Due to the inevitability of waiting time for surgery, this problem seems to have become more pronounced since the outbreak of COVID-19, and due to the high incidence of preoperative hydronephrosis in upper urinary tract urothelial carcinoma (UTUC) patients, it is particularly important to explore the impact of preoperative waiting time and hydronephrosis on upper urinary urothelial carcinoma. METHODS: 316 patients with UTUC who underwent radical surgery at a high-volume center in China between January 2008 and December 2019 were included in this study. We retrospectively collected the clinicopathologic data from the medical records, including age, sex, smoking history, ECOG performance status (ECOG PS), body mass index (BMI), tumor location and size, number of lesions, T stage, N stage, surgical approach and occurrence of hydronephrosis, lymph node invasion, lymph node dissection, surgical margin, tumor necrosis, infiltrative tumor architecture, lymphovascular invasion and concomitant bladder cancer. Surgical wait time was defined as the interval between initial imaging diagnosis and radical surgery of UTUC. Hydronephrosis was defined as abnormal dilation of the renal pelvis and calyces due to obstruction of the urinary system. Firstly, all patients were divided into short-wait (<31 days), intermediate-wait (31-90 days) and long-wait (>90 days) groups according to the surgical wait time. The clinicopathological characteristics of each group were evaluated and the survival was compared. For patients with hydronephrosis, we subsequently divided them into two groups: short-wait (≤60 days) and long-wait (>60 days) groups according to the surgical wait time. Univariate and multivariate COX regression analysis were performed to evaluate the prognostic risk factor for patients with hydronephrosis. RESULTS: A total of 316 patients with UTUC were included in this study with a median surgical wait time of 22 days (IQR 11-71 days). Of the 316 patients, 173 were classified into the short-wait group (54.7%), 69 into the intermediate-wait group (21.8%) and 74 into the long-wait group (23.5%). The median follow-up time for all patients was 43 months (IQR 28-67months). The median surgical wait times of the short-wait, intermediate-wait and long-wait group were12 days (IQR 8-17days), 42days (IQR 37-65days) and 191days (IQR 129-372days), respectively. The 5-year overall survival (OS) of all patients was 54.3%. The 5-year OS of short-wait, intermediate-wait and long-wait groups were 56.4%, 59.3% and 35.1%, respectively (P=0.045). The 5-year cancer-specific survival (CSS) of short-wait, intermediate-wait and long-wait groups were 65.8%, 70.9% and 39.6%, respectively (P=0.032). In the subgroup analysis, we divided 158 UTUC patients with hydronephrosis into short-wait group (≤60 days) and long-wait group (> 60 days), 120 patients were included in the short-wait group and 38 patients in the long-wait group. The median surgical wait times of the short-wait and long-wait group were 14days (IQR 8-28days) and 174days (IQR 100-369days), respectively. The 5-year OS of long-wait group was significantly lower than the OS of short-wait group (44.2% vs. 55.1%, P =0.023). The 5-year CSS of long-wait and short-wait group were 49.1% and 61.7%, respectively (P=0.041). In multivariate Cox regression analysis of UTUC patients with hydronephrosis, surgical wait time, tumor grade, pathological T stage, and tumor size were independent risk factors for OS and CSS. Lymph node involvement was also a prognostic factor for CSS. CONCLUSION: For patients with UTUC, the surgical wait time should be limited to less than 3 months. For UTUC patients with hydronephrosis, the OS and CSS of patients with surgical wait time of more than 60 days were relatively shorted than those of patients with surgical wait time of less than 60 days.

Live Renal Ultrasonography Facilitates Double-J Ureteral Stent Insertion at the Bedside: A Pilot Study for the COVID-19 Era.

Objectives: To investigate the feasibility and efficacy of live renal ultrasonography to guide Double-J ureteral stent placement at the bedside. Patients and Methods: Between April 12 and June 5, 2020, patients presenting with acute ureteral obstruction requiring decompression were prospectively selected for ultrasound-guided bedside ureteral stent placement. During stent placement, upper tract access confirmed using ultrasound with or without retrograde injection of ultrasound contrast before Double-J stent insertion. A postprocedural abdominal X-ray was obtained for stent position confirmation. Results: Eight patients (four men and four women) were offered bedside ultrasound-guided ureteral stent placement, and all eight consented to proceed. Stents were placed in seven of eight patients. One patient had an impacted ureterovesical junction stone and stricture requiring ureteroscopy and laser lithotripsy in the operating room. All patients tolerated procedures without immediate complications. Conclusion: Live renal ultrasonography can facilitate a high success rate for bedside ureteral stent placement outside the operating room. This approach is an attractive alternative to fluoroscopy-guided stent placement in the operating room and is of particular value in the COVID-19 era when judicious use of these resources is salient.