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.

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.

The Development of a Virtual Acute Stone Clinic in a District General Hospital

Introduction: Patients presenting to the Emergency Department (ED) with renal colic are typically managed symptomatically and discharged to a dedicated Stone Clinic to ensure passage of stone. Due to COVID-19 and reduction in Consultant clinic capacity, it became apparent there was an increasing and significant delay in stone patients being reviewed, imaged and referred for intervention. To reduce this delay and associated patient morbidity, a new virtual acute stone clinic (VASC) was developed. Patients and Methods: The VASC involves a Nurse Specialist and Consultant. A new referral pathway from ED was created to ensure baseline imaging, metabolic screen and performance status completed. ED referrals are triaged within 1 week and follow up imaging arranged prior to virtual review (telephone or video consultation) at 4-6 weeks with the SNS. Results: Over three months, 105 patients were reviewed in the VASC, with mean age 52.2 years and 74% men. Time to review was reduced significantly with the mean time being 5.22 weeks. Only 31.4% of patients required Consultant review, primarily for radiolucent, complex stones or medical co-morbidities. After full evaluation, 12 patients were discharged, with 14 listed for stone intervention (ESWL or Ureteroscopy). Conclusion: The VASC has reduced treatment delays, time to be seen and associated morbidity from obstructing ureteric stones. Clinic pressures have been eased and consultant clinic capacity increased by the development of the VASC. The VASC has allowed training and development of the Nurse Specialist skill set with scope to evolve the clinic in the future.

Impact of COVID-19 on the management of ureteric stones in the UK: the COVID Stones study

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.

5 Year review of ureteric stent on strings: Retrospective study at a high volume stone centre52

Introduction & Objectives: Double J ureteric stents are commonly used in acute and elective urology practice. Ureteric stents with external strings offer an alternative solution to extraction compared to the standard of requiring cystoscopy and stent removal at an additional cost. Our aim was to review the usage of double J stents on extraction strings in our institution and whether this was increasing over time and the potential cost savings. Methods: All ureteric stent insertions in Auckland Hospital between 2015 and 2019 (5 years) were reviewed from the hospital stent register. Results: A total of 4016 ureteric stents were inserted over 5 years. Of the total number of stents inserted 33.2% were stents on strings, with a significant increase in the trend towards stent on strings per year (Cochran-Armitage test p<0.0001). Procedures for stone disease were the most common indication for stent insertion making up 66% of all cases. 45% of stents inserted in management of stone disease were stents on strings. The number of stents on strings and total number of stents inserted for ureteric calculi increased each year. If a Covid test cost and subsequent flexible cystoscopy removal of ureteric stent was applied to stent on strings in our study period, a cost saving of $1.15 million would be seen, and is an important consideration for future practice worldwide. Conclusions: The use of stents on strings appears to be higher in our centre than previously reported in the literature. This is likely to be associated with reduced patient discomfort from stent removal and significantly reduced stent removal costs with implications for future planning and resource distribution in our centre. Potential risks associated with stents on strings - in particular stent dislodgement - need to be considered, and consideration given to case selection and patient counselling.

Ureteric stent insertion under local anaesthesia (LA): An effective, safe, and welltolerated alternative to general anaesthesia

Background: The placement of ureteric stents under local anaesthesia (LA) offers the potential for an effective and safe alternative to general anaesthesia in the context of an increasingly co-morbid population and the ongoing COVID-19 pandemic. Objectives: (1) To assess the outcomes for patients with acute ureteric stones managed with the insertion of an emergency ureteric stent under LA. (2) To report the key procedural and logistical elements required to undertake successful LA stent placement. Methods: Patients presenting with CT confirmed, obstructing ureteric stones between 17/04/2020 and 06/07/2021 were included where insertion of an LA ureteric stent was undertaken as an emergency. The primary outcome was procedure success rate and secondary outcomes were serious post-procedure complication rate (defined as Clavien-Dindo. 3), time from CT diagnosis to stent placement, and patient tolerability (defined as pain from the procedure measured on a numerical rating scale 0-10, and reported concern regarding undergoing the same procedure in the future with the options of: no problem/minor problem/moderate problem/major problem). Results: Twenty-three patients underwent emergency LA ureteric stent placement for obstructing calculi with sepsis (73.9%, n = 17), uncontrolled pain (17.4%, n = 4) or acute kidney injury (8.7%, n = 2). The procedural success rate was 95.7% (n = 22/23), and the total number of serious complications was one (4.3%) (ureteric stent migration in duplex system). The median time from diagnosis to stent was 5.3 hours (interquartile range (IQR) = 16.3). The median pain score was 2 (IQR = 5.8), and most patients (73.9%, n = 17/23) reported they would have no problem or a minor problem undergoing the same procedure again. Conclusion: The placement of ureteric stents under LA represents an effective, safe, and well-tolerated alternative to general anaesthesia. The 24/7 availability of a flexible cystoscopy suite, C-arm, and fluoroscopy and specialist urology nurse within a dedicated urology unit has facilitated the delivery of this service.

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.

“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.

Outcomes of a modified Shock Wave Lithotripsy (SWL) service offering multiple sessions and including patients with poor prognostic factors during the Coronavirus pandemic

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.

The effect of COVID-19 outbreak on endourological treatments for urinary stones: A retrospective multicentric study

Introduction & Objectives: The COVID-19 outbreak has brought challenges to the global healthcare community. The management of upper urinary tract stones has been affected even further, with potential severe sequelae for patient’s health.Materials & Methods: We report a multicentric retrospective study involving 9 Centers regularly delivering treatment for upper tract urinary stonesacross the country. All Centers suffered significant limitations during the pandemic period due to government limitations. We compared the 12months-period prior to COVID-19 (from march 1st 2019 to February 28th 2020, named as period A) with post-COVID-19 period (from march 1st,2020 to February 28th, 2021 named as period B). Aim of the study was to compare endourological procedures for upper urinary stones duringperiod A and the period B. This study investigated all types of surgeries for stones delivered in both elective and emergency setting.Results: A total of 4018 procedures were collected, including 2176 procedures in period A. In period B, 1842 procedures were carried out,corresponding to a loss of 15.35% of cases (p<0.001). Looking into elective cases, 1622 procedures were delivered in period A, compared to 1280in period B, resulting in a loss of 342 cases corresponding to 21.81% (p=0.001). All types of stone treatments resulted affected, including ESWL(from 487 cases in period A to 344 in period B, -29.37%, p=0.001), PCNLs (from 170 to 125 cases, corresponding to -26.47%, p:0.008), retrogradesurgery for renal stones (from 433 to 387 cases, -10.63%, p=0.008) and for ureteric stones (from 614 cases to 484, -21.18%, p.008). Additionally,waiting lists resulted affected, with significant delays in period B. In particular, for ureteric stones, mean waiting time in period A was 61.5 dayscompared to 87.5 days in period B (p=0.008). Regarding renal stones, waiting list increased from 64.74 days in period A to 85.66 days in periodB for RIRS. The waiting list for percutaneous surgeries increased from 79 days to 103 days (p.001). We did not find any patient which acquiredCOVID-19 during hospitalization for elective or urgent surgery. We also found a longer waiting list for pre-stented patients, resulting to be 86.5 daysin period B compared to 64 days in period A (p<0.005).Conclusions: Our study showed how COVID-19 caused a significant disruption in endourological services across the country. Our data underlined how less patients received treatment in a longer time. This can potentially lead to an increased risk of stone-related complications, including sepsis and kidney loss

Upper urinary tract stones: Evolution of surgical management trends in Germany, France and England over the past decade

Introduction & Objective: Global Upper Urinary Tract (UUT) stone prevalence is rising. As a consequence, the increased service demand on hospitals may be difficult to manage, increasing the burden on healthcare providers (HCPs) as well as on patients. In this European analysis we explore the evolution of stone diagnoses and surgical procedures in Germany (DE), France (FR), and England (EN) over the past ten years. Methods: We identified the codes related to UUT stones diagnoses using the International Classification of Diseases (ICD-10) and extracted procedure counts for Extracorporeal Shock Wave Lithotripsy (ESWL), Ureteroscopy (URS), Percutaneous Nephrolithotomy (PCNL) and Open Surgery (OS). We used procedure codes from the National databases in DE, FR and EN, and analyzed the hospital diagnosis counts versus surgical procedure counts related to UUT stones from 2010 to 2019. Results: Between 2010-2019, the ICD-10 N20 codes for calculus of kidney and ureter increased by 8%;26% and 15% in DE, FR, EN respectively, whereas stone procedures increased by 3%;38% and 18%. Over time the dominant surgical UUT stone procedure shifted from ESWL (49-60% of all procedures in 2010) to URS (51-75% of all procedures in 2019). PCNL and OS represent <5% of UUT stones procedures in FR and EN. The highest use of PCNL is observed in DE (increase from 7% in 2010 to 11% in 2019). Over the past decade, the overall length of stay (LoS) decreased for all procedures across the three countries. The URS average LoS decreased by 21% in DE;37% in FR and 6% in EN. Daycase stone procedures volume increased in FR by 68% and in EN by 23%. In DE most cases involve at least one overnight stay. Conclusions: This analysis confirms the rise in stone prevalence globally, including an increase in UUT stones diagnoses and surgical procedures in DE, FR, EN over the past decade. The dominant surgical procedure to treat UUT stone has shifted from ESWL to URS, and the average LoS has decreased. These observed trends may be due to clinical advantages, technological advancement as well as, other factors such as HCP preference or costs. The continued rise of UUT stone prevalence has implications for patients, HCPs and hospitals. If we add to that the COVID19 repercussions, solutions to optimize workforce planning, service delivery and length of stay could help to address the situation.

The acute stone clinic model: Improving waiting times and patient care in a public funded health care system

Introduction & Objective: The management of patients with ureteric stones can be logistically challenging in large volume centres with long waits for outpatient clinics and definitive interventions. Many units in publicly funded health systems resort to temporising obstructed kidneys with stent insertion and a subsequent plan for elective ureteroscopy at a later date. This can result in unnecessary stent insertions, repeated attendances to the emergency department and an overall poor experience for patients. We aimed to reorganise resources to improve waiting times for definitive intervention, reduce the need for pre-stenting, reduce emergency department re-attendance and improve the overall patient experience. Methods: All patients diagnosed with ureteric stones between March-September 2017 were collected as baseline data. Time to clinic review and definitive treatment were measured. By collaborating with the emergency department, radiology and operation schedulers, our intervention for improvement where a consultant led acute stone clinic (ASC) with a pathway for primary ureteroscopy was implemented and a second cycle was performed June 2018-January 2019. Further data was collected January-October 2020 to assess performance during the COVID-19 pandemic. Results: After implementing the ASC model, median time from diagnosis to clinic consultation reduced from 77 to 9 days. Median time to definitive procedure reduced from 56 to 25 days. Emergency ureteric stent insertion reduced from 69.1% to 27.9%. Reattendance to the emergency department reduced from 3.0 to 1.6 episodes/month. Primary definitive treatment increased from 31.0% to 72.1%. Patients receiving definitive treatment within 4 weeks improved from 26.2% to 51.2% post intervention and sustained at 54.5% during the pandemic period. Conclusions: Implementation of the ASC model has led to a reduced time from diagnosis to clinic review and from diagnosis to definitive treatment. Further improvement is limited by the lack of extra operating lists to reduce the waiting times for ureteroscopy. The ASC model can provide a blueprint for other hospitals to improve outcomes and care of patients with acute ureteric stones.

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).

COVID-19 pandemic and its effect on supra-regional extracorporeal shock wave lithotripsy (ESWL) service

Introduction & Objective: The COVID-19 pandemic brought significant challenges to all healthcare systems around the world. We studied its impact on our supra-regional ESWL service. Methods: Patients who received ESWL using our onsite lithotripter (Storz Modulith SLX-F2) during the initial National Lockdown (NL) period were compared with those treated over a similar time period in 2019. Patients with renal calculi were excluded for direct comparison as only a small number of patients with renal calculi were treated during NL. As the supraregional centre, we continued to provide acute treatment during NL albeit with restricted access due to staff redeployment, and within safety restrictions, and continued to receive patients from other network centres. Results: 25 patients with ureteric calculi treated in 2019 were compared with 23 patients treated during NL. The mean ages were 56.6 VS 50.0 (2019 VS NL). The mean time to treat were 20.9 VS 19.4 days (2019 VS NL). Two patients' 2nd treatment got delayed during NL. Treatment outcomes are outlined in table 1. The mean residual stone sizes were 4.9mm VS 5.7mm (2019 VS NL). In 2019, complication rate was 16.0% with the commonest being pain (75.0%) when compared to 21.7% during NL (80% pain). Steinstrasse were not seen in either group. One patient treated during NL sustained a moderate peri-renal haematoma managed conservatively. Treatment parameters such as number of shocks delivered and screening time were equivalent between groups. Conclusions: COVID-19 led to pressures on health services and also patients changed their patterns of presentation. Restricted access to the operating theatre made use of non-invasive treatments an essential part of patient management during the lockdown period. We show equivalent outcomes to normal practicedespite treating larger and potentially more challenging stones, with few complications and while minimising COVID- 19-related risks to the patient. (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).

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).

COVID-19 pandemic results in decreased non-urgent urologic-related presentations to the ED

Introduction & Objective: Urologic-related visits to the emergency department (ED) are variable in their acuity, ranging from non-emergent to life-threatening. We sought to evaluate trends in urologic presentations to the ED during the COVID-19 pandemic at a tertiary academic institution in the United States to determine the differences in frequency between urgent and nonurgent visits and further elucidate delayed access to urologic care. Methods: A retrospective analysis was performed comparing the frequency and type of urologic-related ED visits at our institution in January-April 2019 to those in January-April 2020 during the initial pandemic phase. 1,838 urologic presentations between the two-time intervals were organized by diagnosis and divided by acuity into urgent and non-urgent categories. Interrupted time series regression models were used to determine how urologicrelated ED visits changed due to the COVID-19 pandemic. Results: The total number of urologic related ED visits by type for each time interval is demonstrated in Table 1. There was a statistically significant drop in total urologic-related ED visits after the COVID-19 pandemic began, with a drop in total visits of approximately 76 per month (p = 0.002). There was no difference in the number of urgent ED visits due to the COVID-19 pandemic (p = 0.13). However, there was a statistically significant decrease in non-urgent ED visits, with a decrease of 68 visits per month (p = 0.002). When examining the individual visit types, there were no differences in visit volume except for hematuria and nephrolithiasis/ureterolithiasis visits. There was a statistically significant reduction in hematuria-related ED visits, with a reduction in visits of approximately 11 per month (p = 0.03). Similarly, there was a statistically significant decline in nephrolithiasis/ ureterolithiasis-related ED visits, with a decline of approximately 28 visits per month (p = 0.04). Conclusions: The COVID-19 pandemic coincided with a significant decrease in the number of non-urgent urologic presentations to our institution's ED. Specifically, there was a significant decrease in the number of patients presenting with hematuria and nephrolithiasis-related issues. There was no significant decrease in the number of urgent urologic consults. Follow up study is indicated to investigate the effect of delayed evaluation for these non-urgent urologic diagnoses. (Table Presented).