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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.
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Introduction: Abdominal haematomas are an uncommon complication of subcutaneous injection of low molecular weight heparin (LMWH) although the latter is widely administered. Aim(s): To review clinical cases of abdominal haematomas following subcutaneous LMWH injection, discover the root causes and identify appropriate solutions to improve clinical practice. Material(s) and Method(s): Retrospective case review of all clinical cases linked to abdominal haematomas secondary to LMWH injection. Result(s): Between 09.2020-01.2022, 760 patients were admitted in our Department due to COVID19 pneumonia. 4 cases of abdominal haematomas were reported (all females, mean age 70.5 years). All patients received therapeutic LMWH(3 for atrial fibrillation). All patients presented haematomas on rectus abdominis muscle and subsequently in the pelvic area. All patients presented with haemodynamic instability and required blood transfusions. Clinical outcomes included death (1), nephrostomy (1) (due to haematoma expansion and ureteral obstruction) and prolonged hospital stay by 12 days (2). Route cause analysis revealed improper injection technique in the following order;narrow abdominal margins, no skin folding, injection speed<10secs. Solutions were identified and followed including multidisciplinary nursing re-training that was implemented across the board and was accompanied by continuous monitoring of nursing practice. Conclusion(s): The rare complication of abdominal haematomas following LMWH was closely reviewed in our department and was turned into an opportunity to reconsider daily clinical practice, to contribute to quality improvement and improve patient safety.
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OBJECTIVES: To determine if management of ureteric stones in the UK changed during the coronavirus disease 2019 (COVID-19) pandemic and whether this affected patient outcomes. PATIENTS AND METHODS: We conducted a multicentre retrospective study of adults with computed tomography-confirmed ureteric stone disease at 39 UK hospitals during a pre-pandemic period (23/3/2019-22/6/2019) and a period during the pandemic (the 3-month period after the first severe acute respiratory syndrome coronavirus-2 case at individual sites). The primary outcome was success of primary treatment modality, defined as no further treatment required for the index ureteric stone. Our study protocol was published prior to data collection. RESULTS: A total of 3735 patients were included (pre-pandemic 1956 patients; pandemic 1779 patients). Stone size was similar between groups (P > 0.05). During the pandemic, patients had lower hospital admission rates (pre-pandemic 54.0% vs pandemic 46.5%, P < 0.001), shorter mean length of stay (4.1 vs 3.3 days, P = 0.02), and higher rates of use of medical expulsive therapy (17.4% vs 25.4%, P < 0.001). In patients who received interventional management (pre-pandemic 787 vs pandemic 685), rates of extracorporeal shockwave lithotripsy (22.7% vs 34.1%, P < 0.001) and nephrostomy were higher (7.1% vs 10.5%, P = 0.03); and rates of ureteroscopy (57.2% vs 47.5%, P < 0.001), stent insertion (68.4% vs 54.6%, P < 0.001), and general anaesthetic (92.2% vs 76.2%, P < 0.001) were lower. There was no difference in success of primary treatment modality between patient cohorts (pre-pandemic 73.8% vs pandemic 76.1%, P = 0.11), nor when patients were stratified by treatment modality or stone size. Rates of operative complications, 30-day mortality, and re-admission and renal function at 6 months did not differ between the data collection periods. CONCLUSIONS: During the COVID-19 pandemic, there were lower admission rates and fewer invasive procedures performed. Despite this, there were no differences in treatment success or outcomes. Our findings indicate that clinicians can safely adopt management strategies developed during the pandemic to treat more patients conservatively and in the community.
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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.
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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.
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Introduction: Emphysematous pyelonephritis (EPN) is a rare yet life threatening, necrotizing renal parenchymal infection with a mortality rate of 20-25%. With advent of CT, early goal directed therapy with antibiotics, aggressive treatment of sepsis and percutaneous drainage techniques, the mortality and morbidity rates are not as grim as earlier reports. Nephrectomy, treatment of the past has been replaced with nephron sparing surgery with better patient outcomes. A retrospective study was conducted at Government Kilpauk Medical College Hospital between January 2020 and April 2022. Diabetes, obstructive uropathy, structural abnormalities of the urinary tract and immunosuppression are well known risk factors for EPN. Malignancy and associated chemotherapy can make the vulnerable even more susceptible to EPN. The COVID19 pandemic, which was rampant for the past two years, with steroids being the cornerstone of management of COVID pneumonia also contributed to significant immunosuppression and poor glycemic control in many. This study wants to highlight along with traditional risk factors, the impact of COVID19 and Cancer on EPN. Methods: Demographic, clinical, radiological, and microbiological data of 33 patients were recorded. The data were analyzed to study risk factors, treatment modalities, need for hemodialysis, prognostic factors contributing to morbidity and mortality and patient outcome.The initial diagnosis of EPN at presentation was made by ultrasound evidence of gas in renal parenchyma, which was confirmed by CT imaging. Results: Out of a total 33 patients, 64% were females and the median age was 57.5 years. At presentation, common symptoms were abdominal pain (93%), renal angle tenderness (87%), fever (82%), vomiting (75%), dysuria (74%) and oliguria (65.9%). 81.8% (n=27) patients were diabetic. Urinary tract obstruction was present in 33.3% (n=11), Solid organ malignancy related EPN in 21.2% (n=7), with cancers involving kidney and urinary tract predominantly, concomitant COVID infection in 18.2% (n=6) patients, renal transplant EPN in 9% (n=3) of patients respectively. Most common organism was E.coli (60%) followed by Klebsiella spp.(10%), Pseudomonas (8%), Candida spp. (5.6%), Proteus mirabilis (1.4%) and culture negative EPN (15%). CT scoring was done by Huang and Tseng classification. Class I was documented in 28%, Class 2 in 58.8%, Class 3 in 11.8% and Class 4 in 2% of patients. DJ stenting was done in 55% of patients, percutaneous nephrostomy in 3% and the remaining patients improved with antibiotics alone. 35.7% (n=12) required dialysis,10.7% (n=4) were dialysis dependent at the end of three months with 9%(n=3) requiring dialysis indefinitely. Gender, glycemic status or uremic symptoms showed no statistical significance. Sepsis, shock, altered sensorium, higher serum creatinine and hemodialysis dependency had significant impact on patient's outcome. Conclusions: Early diagnosis and treatment with broad-spectrum antibiotics and properly timed interventions decreased mortality. Abdominal pain, renal angle tenderness and fever were the most common symptoms. E. coli was the commonest organism encountered. Solid organ malignancy contributed to a sizable portion of EPN in our study secondary to susceptibility to infections and obstruction. COVID19 infection is a risk factor for EPN due to worsening glycemic status and immunosuppression caused by steroid administration. No conflict of interest
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CASE: A 78-year-old female with a history of recurrent nephrolithiasis and left ureteral reconstruction presented to our institution with hematuria, flank pain, anorexia and weight loss. 3-4 months prior, she had similar symptoms in her home country and was treated with multiple courses of antibiotics. She attempted to present to the US for evaluation earlier, but was unable to due to COVID. She first presented to a nearby US hospital and was diagnosed with an atrophic kidney with a superimposed infection based on imaging and labs. An EGD/ Colonoscopy done for her weight loss was unrevealing. She was discharged on antibiotics and told to follow up for possible nephrectomy. 1 days later, she presented to our institution with continued symptoms. Repeat CT was concerning for emphysematous pyelonephritis. Vital signs were unremarkable. Labs showed no leukocytosis, normal creatinine, hypercalcemia to 13.0 and urinalysis showed hematuria, pyuria and proteinuria. She was initially treated with IV antibiotics and a percutaneous nephrostomy for source control. To continue work up for her weight loss, a CT chest was done that showed multiple lung nodules and a re-review of the CT abdomen noted a T12 lytic lesion. 2 weeks into her admission, she had a left nephrectomy. Pathology revealed an invasive, grade 3, poorly differentiated squamous cell carcinoma arising from the renal pelvis, with lymphovascular invasion. A biopsy of the T12 lesion was consistent with metastasis. Due to her functional status and aggressive nature of her malignancy, palliative therapies were recommended. Patient's course was further complicated by ileus, massive aspiration and spinal cord compression from the T12 lesion. She passed away on hospital day 45. IMPACT/DISCUSSION: Squamous cell carcinoma of the renal pelvis is a rare malignancy. Most present at an advanced stage with a long history of nonspecific symptoms, such as hematuria and/or flank pain, which are typically attributed to recurrent nephrolithiasis;one of the most well-documented risk factors. Additionally, there are no characteristic findings on imaging, making radiological differentiation between renal SCC and other chronic infectious processes difficult. Often there is no suspicion for malignancy until the pathology results. For these reasons, renal SCC should be considered in patients who have underlying risk factors. One may also benefit from a renal biopsy, which can be done before a nephrectomy and has been shown to have a high degree of diagnostic accuracy. Adding to this diagnostic challenge, our patient's care was delayed due to COVID, demonstrating the importance of considering alternative diagnoses when patients have deferred presentations and fractured workups. CONCLUSION: Consider the diagnosis of renal SCC in patients with recurrent nephrolithiasis, UTIs, unexplained hematuria and/or flank pain and refer for a renal biopsy if appropriate. Be mindful of the impact of fragmented and delayed medical care on vulnerable patients.
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Introduction: The objective was to investigate the feasibility, safety, efficacy, and patient acceptability of performing mini-PCNL as a day case procedure. To our knowledge, this is the first reported series in the UK. Method Mini-PCNL data was prospectively collected between April- December 2021. Renal access was achieved by the operating surgeon under fluoroscopic guidance in the prone position. The MIP-M system (Karl Storz, Germany) was used. Stones were fragmented using holmium LASER and retrieved by the Vortex effect and basket. Drainage was via a 6 Fr antegrade stent or 10 Fr nephrostomy tube. Patients suitable for same day discharge were identified using defined preoperative selection criteria. Stone related outcomes, duration of surgery, length of stay, readmission rate and complications were recorded. Results: Fifty patients underwent mini-PCNL (34 male,16 female) with a mean age of 60 years. Mean stone size was 24 mm with a mean operating time of 90 minutes. Twenty patients were suitable for same day discharge. Thirty patients stayed overnight (15 for social reasons, 13 for medical comorbidities and 2 for complications). We recorded 1 case of post-operative sepsis and bleeding requiring embolization. The readmission rate was 0% and 85% were stone free on post-operative CT KUB. Conclusion: Our study shows that day case mini-PCNL is safe, feasible and acceptable in selected group of patients. With the ever-rising pressures on stone services to drive efficiency particularly pertinent with the COVID pandemic, day case mini-PCNL represents an ideal therapeutic option in suitable cases.
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Introduction: In the COVIDStones study, we aimed to determine how management of ureteric stones changed during the COVID-19 pandemic in the United Kingdom. Materials and Methods: The COVID Stones study was a multi-centre retrospective study of consecutive adults diagnosed with CT-proven ureteric stone disease at 19 UK sites. We compared a pre-pandemic period (23/3/19 to 22/6/19) to a period during the pandemic (the 3-month period after the first SARS-CoV-2 case at individual sites). Results: 3755 patients were included (pre-pandemic = 1963 patients;pandemic = 1792 patients). Patients during the pandemic had significantly lower hospital admission rates (pre-pandemic = 54.2% vs pandemic = 46.6%, p<0.001), shorter length of stay (mean = 4.0 vs. 3.2 days, p=0.01), and higher rates of use of alpha-blockers (16.1% vs. 23.3%, p<0.001). In the cohort of patients who received interventional management (n=790 [44.1%] vs. n=686 [34.9%]), rates of ESWL (22.8% vs. 33.9%, p<0.001) were significantly higher;rates of ureteroscopy (56.7% vs. 47.7%, p<0.01) and stent insertion (67.9% vs. 54.5%, p>0.001) were lower;and there was no difference in rates of nephrostomy (p=0.76) during the pandemic. During the pandemic, there was no difference in success of primary treatment overall, including both non-interventional and interventional modalities (prepandemic= 73.8% vs. pandemic=76.2%, p=0.467), nor when stratified by treatment modality or stone size. Conclusions: Despite fewer invasive procedures performed during the pandemic, we demonstrated no difference in success of treatment, without an increase in adverse outcomes. This leads us to question whether the management of ureteric stones can be optimised further.
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INTRODUCTION AND OBJECTIVE: COVID-19 created immense anxiety amongst caregivers and unique strain on healthcare resources which is ongoing. We created a protocol to address this by examining the nature of consults (C) during the pandemic, describe which C needed to be managed in-person, and demonstrated that remote management of many C is appropriate. METHODS: A REDCAP database was used over a six weeks to record urology C at our institution. Data included COVID-status of the patient, reason for C, patient characteristics, and type of intervention required. RESULTS: We received 154 C during the study period. 53% were evaluated in person. 47% were managed remotely. Most common reasons for C were difficult foley catheter placement (21%), obstructing stones(16%), retention (14%) and hematuria (12%). Less common entities included priapism (3%) and Fournier's gangrene (3%). At the time of C 58% were COVID negative, 30% were COVID positive. After evaluation, 44% of C needed no intervention, 27% required a foley, 8% required bladder irrigation and 4% required stenting or nephrostomy placement. Outcomes of those evaluated remotely did not reflect any issues with the care rendered. Fig 1 represents C requests and Fig 2 interventions. CONCLUSIONS: This study showed a higher percentage of C during COVID-19 requiring intervention compared to pre-COVID literature which we successfully identified. 44% did not require acute in-patient intervention. We have shown there is an important role that remote care can and should play in our specialty. Not all C need hands on intervention and studies such as this will result in a safe and logical algorithm for the management of C. With this approach, it became very apparent that not all C are appropriate. This can lead to enhancing the skill set of other house staff. Lastly, the lack of urgency of a large percentage of what we are consulted for becomes apparent. In the face of demands for decreased work hours amongst house staff, strained resources during the pandemic, and the anxiety of the unknown of this virus, we have been able to redefine how C services are delivered.
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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.
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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.
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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.
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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.
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Introduction & Objectives: The Coronavirus pandemic has severely limited theatre capacity and at its peak in England theatre was reserved for lifesaving and emergency surgery. On-going elective theatre capacity remains problematic and so we adapted our service so that all patients presenting acutely with an obstructing ureteric calculus were initially listed for shockwave lithotripsy (SWL). This included patients traditionally expected to have poor outcomes. Furthermore, patients with no stone clearly visible on a plain radiograph would still be listed with an intention to treat should the stone be visible upon fluoroscopic screening at the lithotripter. We also adopted a more flexible approach to our normal protocol for delivery not to exceed two sessions before listing for ureteroscopic surgery (URS). Materials & Methods: Data was retrospectively collected for all patients listed with an intention to treat obstructing ureteric calculi with SWL from the 17th March to 20th October 2020. Patients would be treated using the onsite Storz Modulith SLX-F2 lithotripter where pre-treatment fluoroscopic screening was available. Patients would routinely be listed for 2 sessions of SWL and a Consultant Endourologist would decide whether to proceed with further SWL or URS. Patients with intolerable pain or sepsis would undergo prior insertion of a percutaneous nephrostomy. Results: The stone free rate for 110 patients treated with up to 2 sessions of SWL was 52.7%. If further sessions were delivered the stone free rate increased to 68.2%, following an average of 1.7 further sessions over an average of 21.5 days. Offering further SWL inferred an average cost saving of £888.40-1708.40 per patient by avoiding the additional cost of URS in 17 patients. Our very unselected cohort included 32% with 2 or more poor prognostic factors (upper ureteric, size >10mm, >1000 Hounsfield Units). These patients had a stone free rate of 62.9% following all sessions, compared to 70.7% of those with <2 poor prognostic factors. Only 3 patients listed for SWL with no stone visible on XR KUB were unable to be treated as no stone could be localised on fluoroscopic screening. However 20 patients thought to have non visible stones were able to be treated, and 75% of these patients were stone free after all sessions, avoiding theatre bookings in 15 patients. Conclusions: Offering our SWL service to all patients with obstructing ureteric stones has lightened the burden on theatre demand. Offering multiple sessions is effective, can be delivered in a timely manner and further reduces the need for URS at a lower cost. In addition fluoroscopic screening can be considered to identify stones not visible on XR KUB allowing more patients to be treated with SWL further avoiding theatre bookings.
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Introduction & Objective: The COVID-19 pandemic has provided an impetus to reconsider traditional urologic practices and adapt to the unprecedented healthcare burden. Reducing length of stay after minimally invasive procedures is now more important than ever. Using percutaneous nephrolithotomy (PCNL) as a model, we sought to evaluate clinical barriers to same-day discharge in order to better understand the feasibility of outpatient surgery. Methods: Prospective data collected from 500 inpatient PCNLs performed at our institution between 2016 and 2020 was analyzed via the Registry for Surgery of the Kidney and Ureter (ReSKU). Preadmissions and aborted procedures were excluded. We analyzed issues and complications that warranted postoperative admission. Major categories included infection, bleeding, and excessive pain, which was defined as either a documented pain complication or administration of intravenous opioids within 24 hours after discharge from the recovery room. Multivariate statistics were used to assess risk factors for each outcome. Results: Excessive pain was the most common postoperative issue (40.9%). ASA score was inversely correlated with odds of having increased pain (OR 0.64, 95% CI 0.42-0.98) and was the only statistically significant predictor in our multivariate model that included dilated tract number, diameter, and location. The postoperative SIRS/sepsis rate within 7 days was 9.7%, and higher ASA score (OR 3.6, 95% CI 1.8-7.6) and incomplete stone clearance (OR 2.7, 95% CI 1.2-6.3) were significant predictors. Age, sex, body mass index (BMI), stone burden, and positive preoperative urine cultures were not associated with overall infection rate. In patients who had a postoperative infection, 34.1% of infections were detected intraoperatively or in the recovery room, and 48.8% were associated with the nephrostomy tube removal process on postoperative day 1. Patients who had a postoperative double-J stent rather than a nephrostomy tube had a lower overall infection rate (1.8%, p = 0.047). Finally, only 1.9% of patients had a bleeding complication, and 1.1% required a blood transfusion. Conclusions: Pain is the major barrier to same-day discharge after PCNL. Bleeding is infrequent and most infections can be recognized perioperatively or avoided with alternative tube management strategies. Rigorous patient selection for same-day discharge does not appear to be necessary. Optimizing pain control may be the key to performing outpatient surgery on a large scale.
ABSTRACT
Introduction & Objective: Ambulatory tubeless percutaneous nephrolithotomy (aPCNL) has been shown to be safe and effective in highly selected patients. However, these selection criteria preclude the vast majority of patients that undergo PCNL. The objective of our study was to compare complication and stone free rates after aPCNL in standard selection criteria vs. extended criteria patients. Methods: Retrospective review of prospective data on all patients who underwent aPCNL at one academic center from 2007-2018. Extended criteria patients were defined as any: Age >75 years, BMI >30 kg/m2, ASA >2, bilateral stones, solitary kidney, staghorn calculi, stone burden >40 mm, multiple tracts, or prior nephrostomy tubes/stents. Primary outcomes were complication rates (Clavien-Dindo classification) and stone free rates (no fragments >/ = 3 mm). All patients were discharged with a ureteric stent and no nephrostomy tube after meeting discharge criteria which included hemodynamic stability, no fever, and no significant pain. Results: We identified 118 patients of which 92 (78%) met extended criteria. Mean BMI was 31 kg/m2 and 45% were ASA 3 or higher. Mean sum maximum stone diameter was 24 mm. Multiple stones were present in 25%, bilateral stones in 7%, staghorn stones in 4%, and pre-existing tubes/stents in 4%. There was no difference in complication (12% vs. 18%, p = 0.56), Emergency department visit (12% vs 18%, p = 0.56), or readmission (4% vs. 5%, p = 1) rates between standard and extended criteria patients respectively (Table 1). Of the complications, 85% were Clavien-Dindo grade 1. Stone free rates were not different between standard (84%) and extended (83%) criteria patients (p = 1). No extended criteria variables were associated with complications in univariate analysis. Stone burden >40mm (OR 5.8, 95% CI 1.4-25.2, p = 0.018) and multiple tracts (13.1, 95% CI 1.1-154.7, p = 0.041) were associated with residual stone fragments. Conclusions: Complication and stone free rates were not different between standard and extended selection criteria patients undergoing aPCNL. This data supports the safety and efficacy of aPCNL in patients using extended selection criteria. As the COVID-19 pandemic continues to strain hospital resources, aPCNL offers a solution to deal with a growing backlog of patients with complex stone disease.
ABSTRACT
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.
ABSTRACT
The proceedings contain 818 papers. The topics discussed include: seasonal and COVID pandemic-related variations in patients' self-reported adherence to nutrition recommendations for stone prevention suggest temporal increases in stone recurrence risk;percutaneous nephrostomy in ureteropelvic junction obstruction with poorly functioning kidney: is it still pertinent in adults;kidney stone disease prevalence from administrative coding compared to self-report: a report from the all of US research program;a Delphi process consensus statement on urinary stone treatment during COVID-19: a world Endourological Society TOWER research initiative;prospective non-randomized comparison of transperitoneal transvesical versus extravesical laparoscopic supratrigonal vesico-vaginal fistula repair: a single center experience;identifying patients who will benefit from extended pelvic lymph-node dissection during radical prostatectomy: a novel nomogram based on target biopsy only;and clinical significance of markers of acute renal injury in predicting adverse outcomes in patients with coronavirus infection.