An analysis of stone management over the decade before the COVID-19 pandemic in Germany, France and England.

OBJECTIVES: To understand the implications that the rising upper urinary tract (UUT) stone prevalence in Europe and the increasing burden places on patients and healthcare providers (HCPs), we investigated the evolution of diagnoses and procedures in Germany, France and England over the decade before the coronavirus disease 2019 (COVID-19) pandemic. METHODS: We identified International Classification of Diseases (ICD)-10 codes related to UUT stones diagnosis and extracted procedure volumes for extracorporeal shockwave lithotripsy (ESWL), ureteroscopy (URS), percutaneous nephrolithotomy and open surgery using national procedure codes from the German Institute for the Hospital Remuneration System, the French Technical Agency of Hospitalisation Information and NHS England Hospital Episode Statistics. We analysed procedures vs hospital diagnoses from 2010 to 2019 and reported results per 100 000 inhabitants. RESULTS: Between 2010 and 2019, ICD-10 N20 codes for calculus of kidney and ureter increased by 8%, 26% and 15% in Germany, France, and England respectively; whereas procedures increased by 3%, 38% and 18%. Of the patients diagnosed with stones, the percentage that received treatment (of any type) differed between countries. In 2019, in Germany 83% of patients diagnosed with stones received treatment, in France 88%, and in England 56%. These figures were relatively stable over the 10-year study period. Over the past decade, the dominant procedure shifted from ESWL to URS, and the average length of stay for URS decreased. Day case procedures increased in France and England (by 68% and 23%), no data were available in Germany. CONCLUSION: This analysis highlights an increase in stone diagnoses and procedures, and a shift of surgical management. This development may be due to clinical advantages and advanced technology. The continued stone prevalence rise affects patients, hospitals, and HCPs.

Impact of COVID-19 on the management and outcomes of ureteric stones in the UK: a multicentre retrospective study.

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.

The effect of COVID-19 outbreak on urological procedures for urinary stones: data from three high-volumes centers in China.

China has been the first country to be affected by the COVID-19 outbreak. The pandemic resulted in significant disruption of Health Care Services worldwide, and this effect on treatments for urinary stones is currently unclear. This is the first retrospective study involving three tertiary referral centers for urolithiasis across China. We evaluated surgical volumes and peri-operative outcomes of procedures delivered for upper urinary tract stones. We compared trimester prior to restrictions for COVID-19 (October 1st, 2019 to December 31st, 2019, period A), during restrictions (February 1st, 2020 to March 31st, 2020, period B), and afterword (April 1st, 2020 to June 31st, 2020, period C). A total of 2,543 procedures have been carried out. We observed a loss of 743 cases during period B (-29.2%) and 201 during period C (-7.9%). Percutaneous surgery showed the worst reduction, with 507 mini-PCNLs delivered in period A, 168 in period B (-60.8%), and 389 (-18.3%) in period C (p = 0.001). A worst trend was shown for standard PCNLs with 84 procedures carried out in period A, 5 in period B (-95.2%), and 9 (-89.2%) in period C (p = 0.001). Retrograde surgery also decreased, from 420 cases in period A to 190 cases in period B (-54.8%). An increment was however seen in period C when 468 cases have been carried out (+ 11.4%, p = 0.008). In term of SFRs, a difference was noticed for RIRSs, being 69.2%, 80.5%, and 69.3% during three periods (p = 0.045) and semirigid ureteroscopies (90.3%, 97.1%, and 84.8%, p = 0.013). Charlson's Comorbidity Score could not show any difference between groups as well as no differences in term of post-operative complications have been noticed.

Comparison of shock wave lithotripsy and ureteroscopy in patients with proximal ureteral stones under the COVID-19 pandemic.

PURPOSE: To compare the effectiveness, safety, and cost between ultrasound-guided shock wave lithotripsy (SWL) with an early second session protocol and ureteroscopy (URS) in patients with proximal ureteral stones using the propensity score matching (PSM) method based on a large prospective study. METHODS: This prospective study was conducted in a tertiary hospital from June 2020 to April 2022. Patients who underwent lithotripsy (SWL or URS) for proximal ureteral stones were enrolled. The stone-free rate (SFR), complications, and cost were recorded. PSM analysis was performed. RESULTS: A total of 1230 patients were included, of whom 81.1% (998) were treated with SWL and 18.9% (232) were treated with URS. After PSM, the SWL group had an equivalent SFR at one month (88.7 vs. 83.6%, P = 0.114) compared with the URS group. Complications were rare and comparable between the two groups, while the incidence of ureteral injuries was higher in the URS group compared with the SWL group (1.4 vs. 0%, P = 0.011). The hospital stay was significantly shorter (1 day vs. 2 days, P < 0.001), and the cost was considerably less (2000 vs. 25,053, P < 0.001) in the SWL group compared with the URS group. CONCLUSION: This prospective PSM cohort demonstrated that ultrasound-guided SWL with an early second session protocol had equivalent effectiveness but better safety and lower cost compared with URS in the treatment of patients with proximal ureteral stones, whether the stones were radiopaque or radiolucent. These results will facilitate treatment decisions for proximal ureteral stones.

Does quality of life in patients undergoing shock wave lithotripsy change with repeat procedures: a prospective pilot study from a teaching hospital.

Introduction: Shock wave lithotripsy (SWL) is a well-established treatment for kidney stone disease (KSD) and despite its decreased popularity in the past, it has now gained renewed interest due to its minimally invasive nature and good outcomes, especially in the face of COVID-19 pandemic. The aim of our study was to perform a service evaluation to analyse and identify quality of life (QoL) changes [using Urinary Stones and Intervention Quality of Life (USIQoL) questionnaire] after repeat SWL treatments. This would enable a greater understanding of SWL treatment and reduce the current gap of knowledge regarding patient specific outcomes in the field. Material and methods: Patients affected by urolithiasias underwent SWL treatment between September 2021 and February 2022 (6 months), were included in the study. A questionnaire was given to the patients in each SWL session and consisted of three main topic areas: a domain on Pain and Physical Health, on Psycho-social Health and on Work (see appendix below). Patients also completed a Visual Analogue Scale (VAS) in relation to the pain related to the treatment. Data from the questionnaires were collected and analysed. Results: A total of 31 patients filled in two or more surveys, with a mean age of 55.8 years. On repeat treatments, pain and physical health domain was significantly better (p = 0.0046), psycho-social health domain was significantly better (p <0.001), work domain was significantly better (p = 0.009) and a correlation [on Visual Analog Scale (VAS)] was observed between pain decreasing in subsequent SWL procedures. Conclusions: Our study found that the choice of SWL to treat KSD does improve a patient's QoL. This could be related to improvement of physical health, psychological and social wellbeing, and ability to work. Higher QoL and low pain scores are observed in relation to repeat SWL treatment and are not directly associated to stone-free status.

Primary Definitive Treatment versus Ureteric Stenting in the Management of Acute Ureteric Colic: A Cost-Effectiveness Analysis.

Objectives: To analyze the differences in cost-effectiveness between primary ureteroscopy and ureteric stenting in patients with ureteric calculi in the emergency setting. Patients and Methods: Patients requiring emergency intervention for a ureteric calculus at a tertiary centre were analysed between January and December 2019. The total secondary care cost included the cost of the procedure, inpatient hospital bed days, emergency department (A&E) reattendances, ancillary procedures and any secondary definitive procedure. Results: A total of 244 patients were included. Patients underwent ureteric stenting (62.3%) or primary treatment (37.7%), including primary ureteroscopy (URS) (34%) and shock wave lithotripsy (SWL) (3.6%). The total secondary care cost was more significant in the ureteric stenting group (GBP 4485.42 vs. GBP 3536.83; p = 0.65), though not statistically significant. While mean procedural costs for primary treatment were significantly higher (GBP 2605.27 vs. GBP 1729.00; p < 0.001), costs in addition to the procedure itself were significantly lower (GBP 931.57 vs. GBP 2742.35; p < 0.001) for primary treatment compared to ureteric stenting. Those undergoing ureteric stenting had a significantly higher A&E reattendance rate compared with primary treatment (25.7% vs. 10.9%, p = 0.02) and a significantly greater cost per patient related to revisits to A&E (GBP 61.05 vs. GBP 20.87; p < 0.001). Conclusion: Primary definitive treatment for patients with acute ureteric colic, although associated with higher procedural costs than ureteric stenting, infers a significant reduction in additional expenses, notably related to fewer A&E attendances. This is particularly relevant in the COVID-19 era, where it is crucial to avoid unnecessary attendances to A&E and reduce the backlog of delayed definitive procedures. Primary treatment should be considered concordance with clinical judgement and factors such as patient preference, equipment availability and operator experience.

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.

Urological stone disease: a 5-year update of stone management using Hospital Episode Statistics.

OBJECTIVE: To reassess the trends in upper urinary tract (UUT) stone disease burden and management in the UK during the last 5 years. METHODS: The present paper is our third quinquennial analysis of trends in the management of renal stones in England. Data were collected using the Hospital Episode Statistics database for the years 2015-2020 inclusive. These were then analysed, summarized and presented. RESULTS: The number of UUT stone episodes increased by 2.2% from 86 742 in 2014-2015 to 88 632 in 2019-2020 but annual prevalence remained static at 0.14%. The number of UUT stone episodes in those of working age has remained static but increased by 9% for patients aged > 60 years (from 27 329 to 29 842). The number of shockwave lithotripsy (SWL) treatments decreased by 6.8%. There was a further increase in the use of ureteroscopy (URS) between 2015 and 2020 of 18.9%. Within this subgroup, flexible URS had the most rapid increase in use, with a rise of 20.4% from 7108 to 8558 recorded cases. Over the 20-year period from 2000 to 2020 there was a remarkable 257% increase in URS cases. There was a further decline in open surgery for UUT stone disease by 40%. Stone surgery day-case numbers have increased by 14.7% (from 31 014 to 35 566), with a corresponding decline in the number of bed days of 14.3%. Emergency cases increased by 40%, while elective cases saw a slight increase of 1.9%. CONCLUSION: The present study shows a plateauing in the prevalence of UUT stone disease in England in the last 5 years, with a move towards day-case procedures and an increase in the proportion of emergency work. For the first time in England, URS has overtaken SWL as the most common procedure for treating UUT stone disease, which might reflect patients' or physicians' preference for a more effective definitive treatment.

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 USE OF SPINAL ANAESTHESIA FOR RETROGRADE URETERO-RENOSCOPY DURING THE COVID-19 PANDEMIC

Background The use of spinal anaesthesia (SA) for retrograde uretero-renoscopic surgery is considered to be not as effective as a general anaesthetic (GA) by urologists. However, there were significant concerns associated with GA both for the patient and the anaesthetic team at the height of the COVID-19 pandemic. Our unit was able to successfully transfer surgery to a purpose-built day facility that had extensive experience in delivering SA. This created the opportunity to assess the SA technique in uretero-renoscopy in a cohort of unselected patients. Objective To assess the feasibility of SA as a primary form of anaesthetic for retrograde endoluminal renal and ure-teric surgery. Results Over 4 months, 41 ureteroscopic procedures were performed. The conversion rate to GA (for inadequate analgesia) was 9.8%. Surgical outcome data were compared with an equivalent cohort of patients’ who underwent GA before the pandemic. Both groups had similar outcomes: day-case discharge rate (SA 84%, GA 86%) and surgical completion rate (SA 94%, GA 90%). However, there was a difference in postoperative readmission rate (SA 8%, GA 22%) favouring SA. Conclusions This observational study demonstrated that SA is a safe and effective form of anaesthesia for uretero-renoscopic surgery, delivering non-inferior outcomes to GA. This has implications for the immediate provision of care as COVID-19 continues and as an alternative anaesthetic option to suit patients post pandemic. A larger prospective observational study would be appropriate to clearly define the benefits of SA for ureteroscopy.

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.

Upskirt exposure: The effectiveness of lead skirts to protect the urologist during seated endoscopic stone surgery

Introduction & Objectives: The use of intra-operative image intensifier (II) has increased in urological practice as the mainstay of stone surgery is performed endoscopically. Here we examine the radiation exposure to the groin of the urologist performed endoscopic stone surgery. Our primary aim was to assess whether urologists are exposed to potentially avoidable radiation exposure in the seated position when using vest and skirt lead protection. We hypothesize that the level of exposure is negligible and should not influence surgeon decision on seated versus standing or on lead apron versus skirt and vest combination protective wear. Methods: We conducted a prospective, multicentre study across all public hospitals in the Hunter New England Area Health Network offering Holmium:YAG laser lithotripsy. Routinely, servicing a very large population base, the number of laser lithotripsy cases are quite high however during our research period the coronavirus pandemic diminished the number of elective cases performed. Because of this, we included a total of 50 cases in this study. Small multidimensional-reading dosimeters were worn on the medial aspect of both upper thighs of the urologist under the lead skirt as well as a third dosimeter worn on the outside of the lead protective skirt. All cases were performed with the II in an under-couch position and all cases included were either ureteroscopy or pyeloscopy with laser destruction of urinary stones. In one centre, all surgery was performed by a consultant urologist whilst in another it was all performed by a registrar. Screening time and total dose delivered were prospectively collected using the local network picture archiving and communication system (PACS). This data was analysed by an onsite physicist and collated. After calculating mean and median radiation dose exposures for each dosimeter and grouping those worn under the skirt, comparison was made between dosimeters worn under skirt versus over skirt and Results: Lead gowns reduced radiation dose exposure by 87% (p = <0.01);99% on the side opposite the II and by 76% on the same side of the II (p = 0.2). Mean total dose area product was 88.9 GyCm2 with a mean screening time of 80 seconds per case (range 12-311 seconds). Conclusions: These results support the hypothesis that there is no significant exposure risk in a seated position with vest and skirt combination lead protective wear. An unexpected result was the difference in exposure between the side closest versus furthest away from the image intensifier.

EXAMINING THE 1-YEAR IMPACT OF COVID-19 ON UROLOGY RESIDENT SURGICAL EXPERIENCE: AN ANALYSIS OF NATIONAL SURGICAL CASE LOGS

INTRODUCTION AND OBJECTIVE: The emergence of the COVID-19 pandemic resulted in elective surgical closures beginning in March 2020. In the immediate 6-months after COVID-19 began, there was a significant reduction in national resident operative experience. Our objective is to evaluate the impact of COVID-19 on urology resident surgical experience the year before and after COVID-19 using a national surgical case log registry. METHODS: Canadian national urology resident case log data (T-Res) was analyzed for the 2-year time period from March 15, 2019 - March 14, 2021 with respect to the 14 most commonly performed urological procedures. The 12-month time period prior to COVID-19 was compared to the 12-month time period after COVID-19. Data was analyzed from 11 residency programs with regular active users generating case logs over this time period. Total and specific case volumes per program and per resident user of the time period were analyzed. A paired Wilcoxon signed-rank test was used for comparison of mean cases pre- and post-COVID-19 with an alpha of 0.05 defined as significant. RESULTS: A total of 26,715 procedures were recorded over the 24-month period among 150 unique resident users in 11 training programs. In the 12-months prior to COVID-19, 11,906 procedures were logged while 14,809 procedures were logged in the 12-months after. Nationally, mean total case numbers per program (1082.4 vs. 1346.3;p=0.27) and per resident were not significantly reduced in the 12-months after COVID-19 when compared to 12-months prior (144.5 vs. 135.9;p=0.53). For specific surgeries by program, mean volumes per resident before and after COVID-19 were not significantly different including TURBT (18.5 vs. 19.4;p=0.66), TURP (11.3 vs. 11.7;p=0.72), PCNL (4.1 vs. 3.3;p=0.80), circumcision (6.9 vs. 5.9;p=0.25), hypospadias repair (0.9 vs. 0.6;p=0.39), hydrocelectomy (3.9 vs. 2.6;p=0.37), orchidopexy (4.2 vs. 4.1;p=0.99), ureteroscopy (18.6 vs. 21.3;p=0.53), stent insertion (17.7 vs. 16.7;p=0.77), radical prostatectomy (4.9 vs. 4.8;p=0.89), radical nephrectomy (3.6 vs. 4.0;p=0.75), partial nephrectomy (2.4 vs. 3.0;p=0.29), radical cystectomy (2.8 vs. 3.2;p=0.51), and cystolitholapaxy (3.1 vs. 2.5;p=0.48). While nationally overall case volumes were stable, 3/11 (27.3%) of programs continue to report a significant reduction in surgical volumes 1 year after COVID-19 even when adjusted for number of resident users. CONCLUSIONS: Based on this national case log sample resident operative experience has rebounded one year after COVID-19. However, 27.3% of programs still report significantly reduced case volumes per resident after COVID-19 and this may warrant further examination to ensure focal deficiencies in training don't arise.

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.

Initial experiences of starting a new regional extracorporeal shockwave lithotripsy (ESWL) service during a global pandemic

Introduction: The 2018 GIRFT report and 2019 NICE renal and ureteric stone guidelines recommended regional, fixed-site lithotripsy units to provide elective and emergency extracorporeal shockwave lithotripsy (ESWL) for urinary tract calculus <20 mm. In our region, Trusts were serviced by a mobile lithotripter, which was unable to provide adequate emergency treatment, as such a new fixedsite regional service was developed. Methods: The ongoing pandemic resulted in many challenges in the service development, including a reduction in urological operating by 25% during the COVID-19 pandemic, with additional loss of capacity as only patients ASA 2 or below was able to be treated in peripheral centres. A new pathway was introduced aiming to reduce admissions to surgical wards, instead moving directly to treatment and pain relief at home, in line with the 2019 NHS long-term plan. After 6 weeks of treating local patients, the service was opened to Trusts across the region to enable equal access for all patients' for both emergency and elective ESWL. Results: In the first 6 months, 144 local stones were treated with ESWL (38 ureteric and 106 renal), of which 118 (81.9%) were successfully cleared, with the NICE guidelines quoting success rates between 72.4% and 83.8%. Across that period, this would have required 40 additional operating sessions (160 operative hours) to treat these stones ureteroscopically. With ureteroscopy £2347 more expensive than ESWL to get stone clearance (Constanti et al. BJUI 2020;125: 457-466), the treatment cost saving in the first 6 months is £281,666. In addition, 53 stones were treated as an emergency from the region, with a stone clearance rate of 81% and 53% treated within 48 hours. Conclusion: The new ESWL service has resulted in regional stone treatments with success rates in line with published data, in addition to providing economic and operative capacity benefits during a global pandemic.

Feasibility and safety of daycare pediatric ureteroscopy in low volume centers: Hints to be considered during Coronavirus disease-2019 pandemic

Several guidelines and algorithms have been established since the declaration of Coronavirus disease 2019 (COVID-19) pandemic to organize work across surgical departments and face the enormous demands on health care facilities without affecting patient's health and safety. Pediatric ureteric calculi is an uncommon condition that may be encountered and requires appropriate triage and management. However, pediatric urologists are not available in all centers, mandating adult urologists to deal with such cases despite the small volume, especially during COVID-19, where patients transfer is restricted. We have reviewed pediatric ureteroscopy outcomes at our tertiary center as adult urologists did all cases. We retrospectively reviewed the files of all pediatric patients who had endoscopic management of symptomatic ureteric calculi between 2013 and 2020. Patient demographics, stone characteristics, operative details, hospital stay, and complications were recorded and analyzed. Twenty-one patients were included, 13 males and eight females. The mean age was 8.4 ± 2.9 years. The mean ureteral stone size was 9.9 ±3.6 mm. 28.6% (n=6) of patients known to have other comorbidities, 33.3 %(n= 7) of patients required pre-operative double J stent (JJ) stent insertion. One lithotripsy session was sufficient for complete stone clearance in most patients, 76.2 %(n=16), while the remaining patients required two sessions. None of the patients developed postoperative urinary tract infection (UTI) or gross hematuria with clots. All patients except one were discharged home on the same day. Daycare pediatric ureteroscopy is a feasible and safe option to be considered by adult urologists in order to treat pediatric ureteric stone disease, especially in the current era of COVID-19 pandemic where the number of beds is limited, and patients transfer is restricted. © 2022, An-Najah National University. All rights reserved.

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.

Global Web Trends Analysis of Minimally Invasive Urinary Stone Treatment in the Last Decade and During the COVID-19 Pandemic.

With the rising incidence of urinary stone disease, web searches for stone treatments are increasing. Google Trends (GT) data for a 10-year period and during the coronavirus disease 2019 (COVID-19) pandemic were used to investigate the trend variations for the most popular minimally invasive stone therapies based on time and region. GT can create a line graph that shows how interest in various territories has risen or decreased over time. Search terms were generated for extracorporeal shockwave lithotripsy (SWL), percutaneous nephrolithotomy (PCNL), retrograde intrarenal surgery (RIRS), ureterorenoscopy (URS), and laparoscopic pyelolithotomy/ureterolithotomy. Using the "global" inquiry category, the data were included "worldwide" from January 1, 2009 to December 31, 2021. In recent years, Google and YouTube searches for total minimally invasive stone treatments have increased. RIRS, URS, and PCNL trends revealed a substantial rise in the regression analysis (p < 0.05), but SWL trends showed a significant reduction (p < 0.05). RIRS was the main intervention with interest growing most over time. Web searches for stone treatments decreased in the first period of the COVID-19 pandemic. To a rising degree of involvement, patients and physicians from all over the world utilize the internet to search for minimally invasive stone operations. RIRS, URS, and PCNL are becoming more popular in web trends and SWL still has the highest trend despite the decline in popularity recently. The number of trustworthy web-based tools about stone treatments should be increased, and patients and physicians should be directed to these sources.