A Novel Emr-Based Care Pathway for Nephrolithiasis: Development and 1 Year Utilization

INTRODUCTION AND OBJECTIVE: Patients with acute renal colic due to stones frequently visit the ED. With limited ED resources due to the COVID-19 pandemic, we developed a best practice management pathway within our electronic medical records (EMR) to provide consistent, expeditious and appropriate care for patients with nephrolithiasis. The objective of this study is to describe the development and 1 year outcomes of our EMR Care Pathway for nephrolithiasis. METHOD(S): Our hospital system is composed of many centers. To standardize best practice care, we convened a clinical consensus group, with key stakeholders in emergency medicine, urology, interventional and diagnostic radiology to develop a pathway for the initial work up and management of acute renal colic. AUA guidelines, current literature, and expert consensus across specialties were used to develop the pathway to guide work up and management. Risk assessment tools, and criteria for specific imaging modalities, lab work, and pain protocols were outlined. Criteria for routine discharge with follow-up, including pre-populated links for referrals, indications for urology consult, hospital admission and urgent decompression (stent versus nephrostomy tube) were provided. Data was gathered through the EMR analytics team and descriptive statistics were performed. RESULT(S): The Care Pathway was utilized 944 times from August 3, 2021-September 17, 2022 at 11 different hospitals or care centers (Table 1). Usage increased overtime (r2=0.77). The majority of usage was in the ED (892, 94.4%). A total of 194 providers utilized the Pathway with the majority being residents (64, 33.0%). The pathway included care of 505 unique patients, with 106 primary diagnosis key words triggering pathway use. 139 Urology referrals were placed through the pathway with 124 new 28 day prescriptions of tamsulosin. CONCLUSION(S): An EMR-integrated care pathway has been readily utilized in our system and may augment triage and best practice management of patients presenting with stone disease. Further studies are needed to understand the full impact on outcomes.

Office-Based Ureteral Stent Insertion Without Fluoroscopy under Minimal Sedation is Safe and Effective

Introduction &Objective: Acute renal colic due to obstructing stones has been a challenge for urologists to manage during the COVID-19 pandemic. Due to overwhelmed hospital resources, operating room (OR) time and staff became scarce, resulting in prolonged pain and suffering for patients. Early during the pandemic, we instituted an office-based ureteral stent placement protocol to relieve immediate discomfort. Later with less constrained OR availability, we extended this protocol to patients undergoing chronic stent changes. Method(s): Patients who presented with severe renal colic due to obstructing stones were offered immediate office-based ureteral stent placement under minimal sedation. Patients filled a prescription of diazepam 10mg and were brought to the procedure suite 2 hours later. Intramuscular ketorolac 15mg was given and 2% lidocaine lubricant jelly was inserted per urethra. Flexible cystoscopy was performed with a standard 16Fr scope, and the stent was placed through the cystoscope. For the first two cases, a 0.038" hybrid wire and 4.8fr stent were used while subsequently, a 0.035" stiff hydrophilic nitinol wire and 4.5fr stent were used. No intraoperative fluoroscopy was used. After stent placement, KUB X-Ray was done to confirm stent placement. Result(s): Seven patients (4 females, 3 males) with a mean age of 62.5 years and a mean BMI of 31.3 underwent an office-based procedure. Five stent insertions were done for obstructing ureteral stone (unilateral = 4, Bilateral = 1) and 2 stent changes for ureteral stricture and ureteral obstruction due to fibroids. In most cases, it was clear when the wire had gone past the stone, as there was immediate efflux of urine into the bladder. The efficiency of the procedure was greatly increased by changing the wire and stent size. Stent placement failed in one case due to overfilling of the bladder causing acute angulation of the ureteral orifice. The stent was later inserted under general anesthesia. Conclusion(s): Office-based ureteral stent insertion and exchange are safe and effective even in the absence of fluoroscopy. Further studies are needed to investigate predictors of success of office-based stent insertion, along with cost analysis to expand its use routinely.

Management of Patients Presenting Acutely with Suspected Ureteric Colic

Aim: To assess how patients presenting with suspected ureteric colic are managed compared to NICE guidance (renal and ureteric stones, QS195 July 2020). Also, to review the incidence of ureteric stones occurring in all referrals received in a hospital where patients are referred prior to imaging confirmation of stones. Method: The dataset was formed by retrospective handover screening during a three-month period in 2019 prior to the impact of COVID-19 with any patient included who was referred to urology with a suspected ureteric calculus, generating 149 cases. Demographic information, imaging modality and treatment were recorded as well as comparisons to five NICE quality statements on the management of ureteric stones. Results: Of the 149 referrals 88 were male with a median age of 45 years. Ureteric stones were found in 61/149 of referrals with 99/149 receiving CT scan first line whilst the remainder were initially imaged using ultrasound. Forty referrals were received for women under the age of 50 with only 3/40 having a ureteric stone. Pick-up rate of ureteric stones was higher in older and male patients. CT within 24 hours of referral was achieved in 82.8% and 69.9% were given appropriate analgesia. In patients in which it was necessary primary treatment occurred within 48 hours in 45.4% of patients. Conclusions: Less than half of referrals received had a ureteric stone with particularly low pick-up rates in young women. A large proportion of patients having ultrasound first line had subsequent CT imaging. Adherence to NICE quality standards was comparable to other centres.

The Effect of Covid-19 on the Management of Acute Ureteric Colic in a Tertiary Hospital

Introduction: The Covid-19 pandemic forced changes to care pathways. We have analysed the difference in provision of care to patients presenting with ureteric colic during the pandemic (PC) compared to a pre-pandemic cohort (PPC). Method: A list was generated of all CT KUB scans requested in the emergency department. Imaging and notes were reviewed to identify acute ureteric colic presentations in September to December 2019 and 2020. Statistical significance was calculated using either the Student T-test or Chi-squared test. Results: There were 92 patients in the PC, and 107 in the PPC. Primary treatment was provided for more patients during the pandemic (25% vs 10%, p<0.05), mainly by extracorporeal shockwave therapy (ESWL, 21% vs 7%, p<0.05). The rate of conservative management (64% vs 76%, p>0.05), temporising stent (11% vs 14%, p>0.05), and nephrostomy insertion (1% vs 1%, p>0.05) was similar in PC and PPC. The PC had a shorter time to intervention (17 vs 39 days, p<0.05), to ESWL (4 vs 12 days, p>0.05), to ureteroscopy (35 vs 45 days, p>0.05), and to stone passage confirmation (44 vs 91 days, p<0.05) respectively. There was no follow up for 15% and 30% respectively (p<0.05). Conclusion: During the pandemic, a reduction in electives created capacity for urgent interventions, (21% vs 7% ESWL, 4 vs 12 waiting days). Accordingly, the stone passage confirmation time was more than halved (44 vs 91 days). In accordance with recommendations from NICE, TISU and GIRFT, this demonstrates the importance of ringfencing ESWL, particularly as we emerge from the pandemic.

Efficacy and safety of emergency ureteroscopy as first-line treatment for patients with renal colic due to ureteral stones in the COVID-19 pandemic

Introduction & Objectives: Acute renal colic due to ureteral stones is a common emergency, which can be treated with conservative management, drainage of the kidney and delayed treatment, or emergency intervention. With the outbreak of COVID-19 infection and postponement of elective surgeries, emergency ureteroscopy became a valuable treatment option for acute renal colic in a single-stage setting. The objective of this study is to evaluate the efficacy and safety of emergency ureteroscopy as first-line treatment for patients with acute renal colic due to ureteral stones during the COVID-19 pandemic. Materials & Methods: A prospectively collected database of 120 patients with acute renal colic due to ureteral stone who underwent emergency ureteroscopy within 24 hours from hospitalization between March 2020 and December 2021, was reviewed. Data on patients’ preoperative characteristics, stone-free rates and complication rates was analyzed. Results: Patients’ mean age was 51.4±15.2 years. Male-to-female ratio was 73.3%/26.7%. Mean preoperative serum creatinine values were 120.1±64.1 umol/l. 33 patients (2.5%) had a solitary functioning kidney. Stone location was proximal ureter in 3 patients (27.5%), mid-ureter – in 12 (10%), distal ureter – in 73 (60.8%), distal and proximal ureter – in 2 cases (1.6%). Mean stone size was 8.1±3.3 mm. Stone-free rate after a single procedure was 95% and mean operative time – 25.1±11.5 min. Postoperative drainage was stent JJ in 34 (28.3%) and ureteral catheter for 12h – in 22 (18.3%) patients. 21 patients (17.5%) had a narrow ureter, necessitating the use of smaller caliber ureteroscope (6 Fr). In 2 patients (1.7%) the ureter could not be accessed and a stent JJ was inserted. Intraoperative complications were present in 5 cases – 1 ureteral perforation (0.8%) and 4 cases of upward stone migration (3.3%). Postoperative complications were fever in 2 patients (1.7%) and postoperative renal colic pain - in 7 (5.8%). Conclusions: The results of this prospective study suggest that emergency ureteroscopy is a safe and effective first-line treatment for acute renal colic due to ureteral stones. It offers a one-stage management, without the potential complications of obstruction and loss of renal function due to delayed treatment during the COVID-19 pandemic.

Impact of imaging modality choices on emergency department length of stay for patients with renal colic

Introduction & Objectives: Renal colic is a common presentation to emergency departments. Non-contrast CT is the gold standard for diagnosing ureteric stones. Ultrasound (USS) is also commonly used, however has lower sensitivity and specificity. Uncertainty in imaging findings can delay diagnosis and thereby prolong the length of stay (LoS) in the emergency department. The aim of this study was to assess the current imaging practices for assessment renal colic in the emergency department setting and the impact of imaging modality choices on patient flow. Methods: Patient presentations were identified from Emergency Department Information System for renal colic and urinary calculus diagnosis codes from October 2019 to September 2020. This was correlated with radiology departmental records for imaging modalities used. Clinical records were reviewed for demographics, LoS, disposition, imaging findings and radiation dose. Results: 590 presentations were identified, with 431 first presentations, 86 re-presentations (within 30 days) and 73 interhospital transfers. Imaging was performed in 74.7% of presentations (n = 441). Patients had a median age of 46 years and were mostly male (69%). 73.3% of first presentations had CT as first-line imaging. Those who had USS as first-line imaging were predominantly female (59%) and younger (mean 31.1 vs 46.6 years, p<0.01). They had longer total LOS when compared to CT for first presentations (mean 604 vs 443 minutes, p < 0.01) and all presentations (mean 599 vs 440 minutes, p<0.01). Compared to CT +/- abdominal x-ray, patients having USS were more likely to be admitted to the short stay unit (71.4% vs 43.7%) for longer periods (mean 511 vs 401 minutes, p = 0.05). 17% of patients who initially had USS subsequently had a CT, with this group having the longest mean LoS (total 713 minutes, short stay 720 minutes). Conclusions: USS is more likely to be used in younger and female patients. Compared to CT, first-line USS in renal colic correlated with longer time spent in ED, more admissions to short stay and longer LoS in short stay. Given constraints on hospital resources with the Covid-19 pandemic, renal colic imaging pathways should be examined for opportunities to improve patient flow.

The effect of COVID-19 on the management of acute ureteric colic in a tertiary hospital

Introduction: The COVID-19 pandemic has changed many care pathways. We have analysed the treatment of patients with ureteric colic during the pandemic compared to an equivalent period before it began. Methods: Patients with acute ureteric colic were identified from acute CTKUBs requested in the emergency department from 1 September to 31 December 2020 ('pandemic cohort') and compared to the same timeframe in 2019 ('pre-pandemic cohort'), supplemented by clinical notes review. Results: There were 92 patients in the pandemic cohort, and 107 in the pre-pandemic cohort. Full results are detailed in Table 4. The rates of conservative management (64% vs 76%), temporising stent insertion (11% vs 14%) and emergency nephrostomy insertion (1% vs 1%) was similar in both cohorts (p > 0.05). However, more primary treatment was provided during the pandemic (25% vs 10%) mainly as extracorporeal shockwave therapy (ESWL, 21% vs 7%;p < 0.05). The pandemic cohort also had a shorter time to intervention (17 vs 39 days), driven by more rapid ESWL (4 vs 12 days) and to confirmation of stone passage (44 vs 91 days) (p < 0.05 for all three parameters), whereas the time to salvage ureteroscopy for failed conservative management was equivalent (35 vs 45 days, p > 0.05). Fifteen percent of the pandemic and 30% of the prepandemic cohort were lost to follow-up (p < 0.05). Conclusion: During COVID, reduced elective activity, particularly ESWL for renal stones, created capacity for urgent intervention such that the proportion of patients who had acute ESWL tripled (21% vs 7%) and were treated in one-third of the time (4 vs 12 days). Accordingly, the time to confirmation of stone passage was more than halved during the pandemic (44 vs 91 days). In accordance with recommendations from NICE, TISU, and GIRFT, these data confirm the importance of ringfencing urgent ESWL slots as we emerge from the pandemic.

Primary ureteroscopy for diagnosing and treating acute urolithiasis during the COVID-19 pandemic: Quality and cost benefits

Purpose: The purpose of this study was to investigate the management of acute urolithiasis during index admission by primary ureteroscopy (P-URS) during coronavirus disease-2019 (COVID-19) pandemic. With the rise in prevalence of urolithiasis, the focus has shifted to manage patients presenting with acute ureteric colic during their first admission rather than using temporary measures such as emergency stenting (ES) or nephrostomies which are followed by deferred ureteroscopic procedures Deferred Ureteroscopy (D-URS). We compared the results of ES with P-URS procedures in terms of quality and cost benefits during COVID-19 pandemic. Materials and Methods: Data were collected prospectively from April 2020 to March 2021 for all emergency urolithiasis procedures performed including ES and P-URS. The quality assessment was based in relation to patient factors including the number of procedures per patient, number of days spent at hospital, number of days off work, and expertise of person operating. Cost analysis included theater expenses, hospital stay charges, and loss of working days. Results: This study revealed that the average stay of patients on index admission who had an ES was 1.35 days compared to 1.78 days in patients who underwent P-URS. Patients who had ES had to undergo D-URS and spent another average of 1.5 days in the hospital. Overall, additional expenditure in patients who did not undergo primary ureterorenoscopy was on an average in the range of £1800 (excluding loss of work for patients, who needed to return for multiple procedures). Conclusion: We conclude that the approach of P-URS and management of stones in index admission is very effective in both improving quality of patients (during the COVID-19 pandemic) and bringing down cost expenditure effectively.

“Pseudo-renal colic” – A neglected common entity with significant impact on health service providers’ resources during both pre- and peri COVID-19 pandemic

Introduction & Objectives: Renal colic is a common cause of A&E presentation. A significant proportion of patients presenting with renal colic go onto have entirely normal or pathology free CT scans (“pseudo-renal colic”). Many patients therefore undergo unnecessary radiation exposure from imaging as well as require significant health service providers’ resources. We compared the number of renal colic presentations both pre and peri pandemic period. Materials & Methods: Retrospective data collection was conducted on all CT KUB scans performed in A&E following a clinical diagnosis of renal colic. Data collection, analysis and comparison were performed over two periods - pandemic period of March-May 2020 (first peak of COVID-19) and pre-pandemic period of March-May 2019. Results: In 2019 (pre-pandemic period), 609 patients attending A&E with a clinical diagnosis of renal colic underwent low dose CT KUB. 204 (34%) patients had an index stone in the ureter/PUJ, 141 (23%) had non-stone related pathology (urological and non-urological) and 264 (43%) had pseudo-renal colic. In 2020 (pandemic period), attendances to A&E with a clinical diagnosis of renal colic reduced to 384. During the pandemic, there was significant increase in the proportion of patients with positive CT scans showing a stone in the ureter/PUJ (44% (170/384) vs 34%, p=0.0006) and a drop in pseudo-renal colic patients (34% (130/384) vs 43%, p=0.0032) compared to the pre-pandemic period. The proportion of patients with non-stone related pathology (urological and non-urological) remained relatively stable at 22%. (Table Presented) Introduction & Objectives: Renal colic is a common cause of A&E presentation. A significant proportion of patients presenting with renal colic go onto have entirely normal or pathology free CT scans (“pseudo-renal colic”). Many patients therefore undergo unnecessary radiation exposure from imaging as well as require significant health service providers’ resources. We compared the number of renal colic presentations both pre and peri pandemic period. Materials & Methods: Retrospective data collection was conducted on all CT KUB scans performed in A&E following a clinical diagnosis of renal colic. Data collection, analysis and comparison were performed over two periods - pandemic period of March-May 2020 (first peak of COVID-19) and pre-pandemic period of March-May 2019. Results: In 2019 (pre-pandemic period), 609 patients attending A&E with a clinical diagnosis of renal colic underwent low dose CT KUB. 204 (34%) patients had an index stone in the ureter/PUJ, 141 (23%) had non-stone related pathology (urological and non-urological) and 264 (43%) had pseudo-renal colic. In 2020 (pandemic period), attendances to A&E with a clinical diagnosis of renal colic reduced to 384. During the pandemic, there was significant increase in the proportion of patients with positive CT scans showing a stone in the ureter/PUJ (44% (170/384) vs 34%, p=0.0006) and a drop in pseudo-renal colic patients (34% (130/384) vs 43%, p=0.0032) compared to the pre-pandemic period. The proportion of patients with non-stone related pathology (urological and non-urological) remained relatively stable at 22%. Conclusions: Pseudo-renal colic comprised around 40% of renal colic patients during both the pandemic and non-pandemic period leading to unnecessary radiation exposure and wastage of precious resources. Patients with pseudo-renal colic possibly experience less pain than genuine ureteric colic and a significant proportion stayed at home during the pandemic. Clinical assessment with the use of the validated Stone Score as well as markers such as WC, CRP and renal function before ordering a CT KUB in suspected renal colic patients may help reduce the number of unnecessary CT scans in the future as well as minimize the strain on health service providers’ resources during and after the pandemic.

The real impact of the delay in presenting to the emergency department with acute renal colic: which patients are at risk?

Introduction & Objectives: The optimum length of time for conservative treatment in patients with acute renal colic is unclear and there is no clear consensus on the time scale. The aim of this study is to verify the impact of delay on biochemical and clinical outcomes for patients presenting to the emergency department (ED) with acute renal colic. Materials & Methods: Data were retrospectively collected from three institutions from two European countries from 01 January to 30 April 2020. Patients who presented to the ED with unilateral or bilateral renal colic caused by imaging confirmed urolithiasis were included. Exclusion criteria were: flank pain not caused by urolithiasis, Chronic Kidney Disease (CKD) grade >II and solitary kidney. Patients with a SARS-CoV-2 positive PCR swab test were excluded. Presentation after 24 hours since the onset of symptoms was considered a delay. Patients presenting before 24 hours from the symptom onset were included in Group A, while patients presenting after 24 hours in Group B. Clinical and biochemical parameters and management were compared. Continuous parametric and non-parametric data were analyzed with Student’s t-test and Mann-Whitney U test respectively. Categorical variables were analyzed with Chi-squared test. All statistical tests were two sided with the significance level set at 0.05. Results: 397 patients who presented to ED with confirmed urolithiasis were analysed (Group A, n= 199;Group B, n=198). The median (IQR) delay in presentation was 2 days (1,5-4). At presentation, no statistically significant differences were found amongst the two groups of patients regarding presenting symptoms such as fever and flank pain, and the median serum levels of creatinine, C reactive protein and white blood cells (see Table 1). No differences were found in terms of conservative or operative management. (Table Presented) Conclusions: In stable and selected patients, the clinical and biochemical parameters do not tend to worsen in the first days following the first renal colic. Most patients with suspected renal colic do not necessarily need urgent attendance to the ED and may be managed as outpatients.

Management of acute ureteric colic in a large tertiary centre during the initial COVID-19 pandemic - How did our practice change?

Introduction & Objectives: Treatment of acute ureteric colic according to current BAUS guidelines can be challenging, particularly during the COVID-19 pandemic. We aim to audit our practice during the initial COVID-19 pandemic. Materials & Methods: A retrospective analysis of 94 patients admitted with ureteric colic during the initial COVID-19 pandemic (March to June 2020). Data was collected from records and outcomes compared to a pre-pandemic audit of our acute stone service (January to June 2018). Results: Patient demographics were comparable: 33 admissions/month (pre-COVID 37), average age 52 years (pre-COVID 53 years), and median stone size 6 mm (pre-COVID 5mm). Septic patients (23%, pre-COVID 17%) underwent ureteric stenting (23%, pre-COVID 17%) or nephrostomy (10%, pre-COVID <1%). For non-septic patients, 46% underwent primary treatment (ureteroscopy:ESWL = 1:1, pre-COVID = 2:1), 24% ureteric stenting (pre-COVID 31%) and 30% conservative management (pre-COVID 34%). Median time to primary ureteroscopy (94% successful) and ESWL (76% successful;1-2 sessions) was 24 hours (target <48 hours). Median time from stent insertion to definite ureteroscopy was 5.8 weeks (pre-COVID 6.6 weeks, target <4 weeks) and subsequent cystoscopic stent removal was 4 weeks (target <2 weeks). For patients managed conservatively, median time to outpatient review was 7.1 weeks (pre-COVID 5.4 weeks, target <4 weeks) and follow-up imaging 8.2 weeks. Conclusions: These results from one of the largest stone units in the UK show, that despite the pandemic, primary stone intervention was still achievable within 24 hours. There was a greater reliance on ESWL and nephrostomy insertion due to concerns regarding general anaesthesia and COVID-19.

Head to Toe Imaging of Complications and Sequelae of COVID- 19 and COVID-19 Vaccination

Background. COVID 19 is associated with a hypercoagulable state with cytokine storm syndrome and thrombocytopenia leading to complications across various systems. COVID-19 infection, its treatment, resultant immunosuppression, and pre-existing comorbidities have made patients vulnerable to secondary infections Methods. We systematically reviewed COVID-19 cases between Jan to May 2021 for pulmonary and extrapulmonary complications. Patients with recent COVID-19 vaccination and neurological symptoms were also included. Results. Neurological complications: Neurological complications include ischemic and haemorrhagic strokes. Other complications are encephalopathy, encephalitis, Guillain-Barré syndrome, acute hemorrhagic necrotizing encephalopathy. Demyelination and radiculopathies are seen as post vaccination complications. Mucormycosis: Unprecedented high rate of invasive fungal sinusitis in association with COVID -19 is reported from the Indian subcontinent. This has a propensity for intra orbital and intracranial extension. COVID -19 associated coagulopathy: COVID -19 is a pro-inflammatory hypercoagulable state. Pulmonary thromboembolism, deep venous thrombosis and catheter related thrombosis are well documented. Cardiac complications: Cardiac manifestations include Myocardial Injury with non-obstructed coronary arteries (MINOCA), myocarditis, myocardial ischemia, cardiomyopathy. Pulmonary complications and sequelae of COVID -19: Progression of lung injury to ARDS during the initial phase and fibrosis of parenchyma in the recovery phase. Spontaneous pneumomediastinum, pneumatoceles and pneumothorax and secondary infections are identified in our study. COVID- 19 associated gastrointestinal complications: Patients evaluated for renal colic, pancreatitis, cholecystitis showed, ground glass opacities or subpleural bands in typical Covid-19 distribution. COVID-19 may lead of acute kidney and bowel injury due to arterial thrombosis. COVID - 19 associated myonecrosis: Ischemia of the small caliber vessels may result in myonecrosis. Conclusion. Awareness of these unusual manifestations will facilitate an early diagnosis, improve management and help reduce morbidity and mortality.

A delphi process consensus statement on urinary stone treatment during COVID-19: A world endourological society TOWER research initiative

Introduction & Objective: COVID-19 continues to have a profound effect on urolithiasis management with varying recommendations for prioritization across different healthcare systems. We used the Delphi method to obtain international consensus recommendations for managing urolithiasis during the pandemic. Methods: 53 key opinion leaders from 36 countries within the Endourological Society contributed to a three-round Delphi process addressing the general organisation, inpatient and outpatient management and follow-up care of urolithiasis patients to determine best practices for suspension and resumption of care. Results: Consensus was achieved in 64/84 (76%) questions allowing the following recommendations to be made for the management of Urolithiasis during the pandemic. 1 Consultations should ideally be delivered via telephone or video conferencing, prioritizing patients with Infection, acute kidney injury, pain including acute ureteric colic and visible haematuria. 2 The Surgical focus should be to reduce the risk of complications even if it means a planned secondary procedure 3 Surgery should be reserved for high risk patients (solitary kidney, bilateral ureteral obstruction), infected patients, patients at risk of acute kidney injury or those with uncontrollable pain. 4 Primary definitive treatment of obstructing or symptomatic stones (both renal and ureteral) is preferred over temporizing drainage. 5 ESWL should be continued for ureteric stones but not for asymptomatic renal stones 6 Spinal Anaesthesia was recommended for distal Ureteric Stones under 10mm 7 For symptomatic renal stones, Flexible ureterorenoscopy (FURS) was recommended for 11-20mm and PCNL/ ECIRS for stones >20mm 8 Following Uncomplicated URS/FURS “Stent-on-astring” was recommended for stones 5-20mm at all positions, with “stent and cystoscopic removal” for stones >20mm at all locations 9 Following Complicated URS/FURS stent and cystoscopic removal was recommended for all stone sizes and locations. 10 Following PCNL, some form of drainage was recommended for all complicated PCNLs and for uncomplicated PCNL for stones >11mm. 11 Surgical education should be maintained for trainees involved in the patients care. 12 Follow up imaging should continue for conservatively and actively treated ureteric colic and for patients with symptomatic renal stones 13 Imaging follow up can be deferred for asymptomatic prior stone formers including those with an established renal stone. Conclusions: These recommendations can be applied currently during the ongoing Covid-19 pandemic and be used as a framework for practice during a future catastrophic event that impacts the practice of renal and ureteric stone surgery.

The impact of the COVID-19 pandemic on the presentation and management of renal colic patients

Introduction & Objective: Renal colic is one of the common urological emergencies. As the COVID-19 pandemic significantly impacted the UK healthcare system, there were some changes in the presentation and management of renal colic patients during the pandemic compared to the pre-pandemic period. We compared the presentation and management of renal colic patients between the pandemic and pre-pandemic period. Methods: Retrospective data analysis from electronic patient records was conducted for all adult patients presenting to our A&E department with a radiological diagnosis of renal colic between March-May 2020 (the first peak of the pandemic) comparing similar data collected for the period March-May 2019. Results: During the pandemic, the total number of patients attending A&E with a clinical diagnosis of renal colic and CT scan confirming stone in ureter/PUJ reduced by 17% compared to the same period in 2019 (170 vs 204). Relatively younger patients attended A&E during the pandemic compared to the pre-pandemic period (median age in years [IQR] - 43.5 [34, 52] vs 39 [31, 50], p = 0.016) and there were significantly more patients with PUJ stones in 2019 than in 2020 (18 vs 1, p = 0.0003). However, there was no difference in other patient characteristics or stone characteristics. Also, there was no difference in the proportion of patients managed conservatively between the pandemic and prepandemic period (79% vs 78%, p = 0.83). However, between 2020 and 2019, there was a significant reduction in hospitalization (18 (10.6%) vs 49 (24%), p = 0.0008), JJ stent insertion (6 (3.5%) vs 24 (11.7%), p = 0.004) and ureteroscopy as initial definitive treatment (4 (2.4%) vs 29 (14.2%), p = 0.0001) along with a significant increase in primary ESWL (25 (14.7%) vs 9 (4.4%), p = 0.0006). Conclusions: The COVID-19 pandemic resulted in a considerable drop in A&E attendance of renal colic patients. The reduction was more noticeable in older patients compared to the younger patients. In addition, there was change in standard management strategy from stent insertion followed by a second admission for ureteroscopy towards urgent primary ESWL. (Table Presented).

“Pseudo-renal colic”-a neglected common entity with significant impact on health service providers' resources during both pre-and peri-COVID-19 pandemic

Introduction & Objective: Renal colic is a common cause of A&E presentation. A significant proportion of patients presenting with renal colic go onto have entirely normal or pathology free CT scans (“pseudo-renal colic”). Many patients therefore undergo unnecessary radiation exposure from imaging as well as require significant health service providers' resources. We compared the number of renal colic presentations both pre and peri pandemic period. Methods: Retrospective data collection was conducted on all CT KUBscans performed inA&Efollowing a clinical diagnosis of renal colic. Data collection, analysis and comparison were performed over two periods - pandemic period of March-May 2020 (first peak of COVID-19) and pre-pandemic period of March-May 2019. Results: In 2019 (pre-pandemic period), 609 patients attending A&E with a clinical diagnosis of renal colic underwent low dose CT KUB. 204 (34%) patients had an index stone in the ureter/ PUJ, 141 (23%) had non-stone related pathology (urological and non-urological) and 264 (43%) had pseudo-renal colic. In 2020 (pandemic period), attendances to A&E with a clinical diagnosis of renal colic reduced to 384. During the pandemic, there was significant increase in the proportion of patients with positive CT scans showing a stone in the ureter/PUJ (44% (170/384) vs 34%, p = 0.0006) and a drop in pseudo-renal colic patients (34% (130/384) vs 43%, p = 0.0032) compared to the pre-pandemic period. The proportion of patients with non-stone related pathology (urological and non-urological) remained relatively stable at 22%. Conclusions: Pseudo-renal colic comprised around 40% of renal colic patients during both the pandemic and non-pandemic period leading to unnecessary radiation exposure and wastage of precious resources. Patients with pseudo-renal colic possibly experience less pain than genuine ureteric colic and a significant proportion stayed at home during the pandemic. Clinical assessment with the use of the validated Stone Score as well as markers such as WC, CRP and renal function before ordering a CT KUB in suspected renal colic patients may help reduce the number of unnecessary CT scans in the future as well as minimize the drain on health service providers' resources during and after the pandemic. (Table Presented).

The effect of the COVID-19 pandemic on management of urological emergencies including risk of contracting COVID-19-a UK epicentre experience

Introduction & Objective: During the first wave of COVID-19 we saw a reduction in urgent urological admissions. Concurrently, we had to adapt and change our standard management of urological emergency admissions. We wished to evaluate the impact of COVID-19 on urological emergencies in a UK COVID-19 epicentre. Methods: Retrospective audit of all urological emergencies over a 10-week period (mid-March - end of May) in 2019 was compared to the same period during COVID-19. Results: From 2019 to 2020 we saw a reduction of 35% (187 [2019] and 122 [2020]) in urological emergency admissions. The average inpatient stay was 1.76 days (range 0-24 days) in 2020 from 2.65 days (range 0-38 days) in 2019. The largest reduction in presentation was seen in renal colic 43% (58 [2019] and 33 [2020]) followed by visible haematuria 39% (37 [2019] and 23 [2020]). There was a decrease in surgical management of urological emergencies during COVID-19. Scrotal exploration for testicular pain went from 57% (21 of 37) 2019 to 39% (12 of 31) during COVID-19. Stenting for colic and confirmed ureteric stones decreased from (20 of 25) 80% in 2019 to 11% (2 of 18) in 2020. “Hot” ESWL rates for ureteric stones increased from no patients [2019] to 61% (11 of 18) in 2020. In 2019, 12% (6 of 49) of emergency procedures were performed by Consultants however this increased to 48% (11 of 23) in 2020 due to redeployment of urological registrars. The overall in-hospital COVID-19 infection rate was only 0.82% during or within 28 days of discharge with no COVID-19 related mortality (0%). Conclusions: Inpatient infection rate from COVID-19 was very low and there was no related mortality therefore patients should not fear hospital attendance or admission. Longer term follow-up of patients managed conservatively rather than surgically is necessary to ensure no long-term harm has been caused by a change in standard surgical management of urological emergencies. (Table Presented).