Decision Making and Treatment Options in Endourology Post-Coronavirus Disease 2019

Adapting To The Future

Silvia Proietti; Mario Basulto-Martinez; Maria Pia Pavia; Lorenzo Luciani; Franco Gaboardi; Guido Giusti

Disclosures

Curr Opin Urol. 2021;31(2):109-114. 

In This Article

Abstract and Introduction

Abstract

Purpose of Review: To describe and critically discuss the most recent evidence regarding stone management during the coronavirus disease 2019 (COVID-19) and post-COVID-19 era.

Recent Findings: There is a need to plan for resuming the normal elective stone surgery in the post-COVID era, keeping a clear record of all surgeries that are being deferred and identifying subgroups of surgical priorities, for the de-escalation phase. Telehealth is very useful because it contributes to reduce virus dissemination guaranteeing at the same time an adequate response to patients' care needs. Once the pandemic is over, teleurology will continue to be utilized to offer cost-effective care to urological patients and it will be totally integrated in our clinical practice.

Summary: This COVID-19 pandemic represents a real challenge for all national health providers: on the one hand, every effort should be made to assist COVID patients, while on the other hand we must remember that all other diseases have not disappeared in the meanwhile and they will urgently need to be treated as soon as the pandemic is more under control. A correct prioritization of cases when surgical activity will progressively return back to normality is of paramount importance.

Introduction

On March 11, 2020, the World Health Organization (WHO) characterized the coronavirus disease 2019 (COVID-19) as a pandemic.[1]

The initial wave of this outbreak has disrupted non-COVID-19 healthcare services and threatened the ability of the medical system to respond to routine patient needs; also, urological procedures were significantly cut-back worldwide, and benign diseases were the most affected.[2,3]

As the curves flattened, the hospitals have restarted routine surgical activities, though with a significantly longer waiting list. Unfortunately, right now, we are witnessing the second wave of this fluctuating and prolonged pandemic and there is a need to de-escalate again surgical activities.

Even though urolithiasis is considered a benign disease, it could be time-sensitive in terms of functional and infective outcomes. As a matter of fact, urinary stone disease may become a life-threatening condition if not managed in a timely manner.[4]

Moreover, with a global incidence of around 10%, stone disease is becoming a major healthcare issue; over the last decade, it has been reported a rising prevalence of kidney stone disease with associated increase in the number of interventions related to it.[5] Therefore, stone management is not inconsiderable during this pandemic.

The aim of this review is to formulate management proposals for stone patients during the COVID and post-COVID era in order to minimize COVID-19 transmission and, at the same time, to manage urolithiasis, on the basis of international guidelines and clinical experience aiming to prevent any severe complications.

Prioritization Strategies for Stone Patients During the COVID-19 Era

Soon, after the beginning of the pandemic, urologists provided recommendations for managing patients during the COVID-era.[6–9]

The European Urological Association (EAU), in light of this pandemic, has reviewed the guidelines and adapted where appropriate to deal with the urgent crisis impacting urological care and services.

Regarding urolithiasis, EAU Guidelines created a surgical prioritization scheme that categorized stone patients in four priority categories: low, intermediate, high priority and emergency.

Depending also on the emergency status of the hospital, the choice of urinary system decompression should take into consideration the possibility for outside procedures or at bedside, sparing an anaesthetist and a ventilator whenever possible.

Ureteral stents might be preferred due to the high risk of inadvertent nephrostomy dislodgment with consequent need of re-positioning and a possible long-wait until definitive stone treatment.[6]

Medical expulsive therapy should be pursued as a potential tool for avoiding surgical intervention.[6]

In addition, Proietti et al.[8] suggested a priority line for stone patients scheduled for surgery during the COVID-19 pandemic, creating four groups of surgical priority, ranging from the procedures that might be delayed to those that cannot be delayed.

Stent indwelling time, urinary infections and symptoms may be factors to consider for moving patients to a higher subset in the priority list.

Moreover, Metzler et al.[9] have built another timeline for scheduling and prioritizing stone patients; they categorized them into five groups from emergent situations to cases that could be postponed.

The authors highlighted the fact that their scheme should be actualized for each case, considering that many nuances contribute to individualized care that could shift a patient between categorization levels of urgency.

The de-escalation of surgical activity should depend on the emergency status of individual healthcare systems and what each hospital requires of the urological departments.

As the pandemic crisis improves or resolves, categorization will help the return to long-lasting normality in the hospitals.

Stone Patients and Emergency Department During the COVID-19 Era

Recent studies have shown a significant reduction in ED visits related to urinary stone disease over the first weeks of the pandemic.[10,11]

In Italy, during the first wave of this outbreak, the lowest peak of ED visits corresponded with the highest peak in the COVID-19 daily mortality trend.

This may be interpreted, on the one hand, as an overuse of the ED by cases of low complexity during normal times that could be managed by general practitioners, or alternatively in some cases, an alarming tendency to postpone consultations, even when necessary, because of the fear of getting infected with COVID-19.[12]

This delay may lead to more severe clinical conditions at presentation with potential serious sequelae for the patients.

Kachroo et al.[13] reported a higher proportion of stone patients with acute kidney injury in the COVID era compared to an equivalent pre-COVID era (4.7% vs 2.6%), potentially related to a delay in ED presentation.

In another study, the authors stated that the urological ED admissions per day were lower (P < 0.0001) and the need of urgent surgeries and hospitalization was higher (P = 0.02 and P < 0.0001 respectively) during the lockdown period compared to one year before.[14]

Additionally, it has been reported that the rate of complicated ureteral stones increased during the COVID-19 restrictions period compared to the non-COVID era, characterized by a longer hospital stay and a higher need for antibiotic treatment with carbapenems.[15]

General Recommendations for Stone Patients During COVID Era

Renal Colic. Patients with renal colic should be managed conservatively as much as possible to avoid admission to an already overwhelmed ED.

So far, there is no a clear evidence establishing a connection between the worsening of COVID-19 and the use of nonsteroidal anti-inflammatory drugs (NSAIDs), as such, as suggested by Pradère et al.,[16] a pragmatic approach could be to avoid NSAIDs in COVID-19 patients, following the same guidelines that we follow for pregnant women.

Having said this, it is important also to highlight that NSAIDs are still the most efficient therapy for renal colic and, last but not least, some of them are available over the counter, which is not a minor matter during a pandemic.

Stone Treatment. Apart from the aforementioned urgent/emergency stone cases, outpatient procedures should be pursued and stents with strings should be considered whenever possible, after uneventful procedures, to avoid an additional outpatient procedure for stent removal.[17] The adoption of single-use cystoscope is suggested when cystoscopy suite slots and related personnel availability are not enough to cover all requests for stent removal during the pandemic: with this sort of device a single personnel unit can perform the procedure outside the cystoscopy suite in a normal office or even at bedside if needed.[18]

Moreover, when the stone-free rate (SFR) can be achieved in one single procedure with few additional resources, without increasing the risk of postoperative complications, it is advisable to treat a stone instead of temporary drainage only, to minimize repeated healthcare exposures and avoid increasing an already long waiting list.[9]

Along with this concept, in order to best use all operating room slots, in case of bilateral renal/ureteral stones, in selected cases, bilateral endoscopic surgery including also simultaneous procedures (SBES) should be taken into account to obtain SFR bilaterally in one single session, without encountering an increased risk of postoperative infective complications.[19,20]

Shockwave lithotripsy (SWL) could be an option in the COVID-19 era allowing for social distancing, for less personal protective equipment (PPE) than a surgical procedure and no need for anaesthesia;[17] nevertheless, although it is difficult to balance the pros and cons of every approach, ureteroscopy should be preferred over SWL for higher SFR and lower retreatment rate, especially in an emergency setting when steinstrasse might develop.[21]

Silicone stents should be preferred to polyurethane stents for the lower encrustation rate[22] and significantly less patient discomfort.[23]

Infection associated with ureteral stents, in some situations, can lead to significant morbidity such as acute pyelonephritis, bacteremia, urosepsis and even death.[24] Therefore, this group of patients should be considered with some priority in order to avoid an excessively extended delay.[8]

In addition, the evidence of viral presence in urine is sparse; according to a recent review, SARS-CoV-2 was found in only 6.9% of patients; nonetheless, until further research provides robust data on viral shedding and virulence in urine, the potential risk of transmission through urine cannot be excluded.[25]

For this reason, provided that the cleaning process is correctly performed, standard sterilization of reusable armamentarium should be considered safe; however, wherever economically sustainable, the use of single-use ureteroscopes could be a wise solution, thereby avoiding any risk of cross-contamination with the virus.

Teleurology. Telemedicine has been available even before the COVID-19 pandemic and the growth of telehealth was one of the most important trends in healthcare delivery; it aligns with our modern technological society, reducing time, personnel hours and costs.

In particular, during this pandemic, telehealth is very useful because it allows to keep more patients at home and, consequently, to reduce virus transmission, especially inside hospitals guaranteeing at the same time an adequate response to patients' care needs.

Luciani et al.[26] showed the benefits of telemedicine compared to cancellation during the pandemic, in particular in patients with high risk urological malignancies and potential severe clinical conditions (complicated urinary stones or infections); the virtual clinic proved a pragmatic approach for an efficient screening of cases and for providing adequate safety for patients and healthcare workers.

A recent survey has demonstrated that most patients are willing to use telehealth, even though some barriers still exist, especially the preference for in-person care.[27]

In the urolithiasis setting, the difficulty in performing a radiological examination before a virtual visit could be another barrier during the pandemic.[17]

Nonetheless, medical staff should promote telemedicine, delivering the message that telehealth is an effective alternative and, most importantly, safer than face-to-face consultation during a pandemic.

Definitely, once the pandemic is over, teleurology will continue to be utilized to offer cost-effective care to urological patients and it will be totally integrated into our clinical practice.

Notwithstanding this, telemedicine must be considered a medical act, thus there are some legal implications still lacking a shared international and national consensus.

As a matter of fact, privacy may be manipulated and poorly protected, distance consultation may not reach the appropriate standard of care and the distinction of responsibilities and potential obligations among each care-giver may be challenging.[28,29]

With the increased dissemination of telemedicine, governments and medical associations should promote common legal, regulatory, ethical and administrative standards.[30]

Covid-19 Era and Patients' Perspective. As previously mentioned, the COVID-19 outbreak led to a devastating reorganization of the elective surgical activities; from the patients' point of view, the choice to undergo surgery during this pandemic could be particularly demanding, taking into account, on the one hand, the risk of delaying the intervention with possible health consequences in terms of both outcomes and complications, and on the other hand, the risk of getting infected with the virus.

In a recent patients' survey, Campi et al.[31] reported that 47.9% of patients would have deferred the planned surgery because of the COVID-19 pandemic, with nearly 85% of them willing to postpone it for at least 6 months.

Reasonably, the percentage of patients refusing surgical intervention was higher among those with benign disease compared to those with oncological problems (P < 0.001). In contrast, among the benign urological disease group, stone patients asked less frequently to be deferred compared to other patients (P < 0.004).

Overall, 54.8% of patients considered the risk of contracting the virus more dangerous than the risk of delaying surgery.[31]

In light of these findings, the need for meticulous patients' counselling is of paramount importance to lower the risk of complications in cases where surgery is delayed by a patients' choice.

Increased Risk of Urinary Stone Formation During the COVID-19 Pandemic. National lockdowns, with social distancing and homestay, have been already proven effective to contain COVID-19 and to stop the exponential growth of this contagion.

Nevertheless, a large UK survey has reported changes in weight-related behaviours and barriers to healthy eating and physical activity as a result of the COVID-19 lockdown.[32]

In addition, according to another large survey, the mental health burden associated with the COVID-19 social lockdown, characterized by the feeling of being more lonely, depressed and anxious, had contributed to lower levels of physical activities and more overeating among participants.[33]

All these aforementioned conditions translate into a considerably higher risk of developing or worsening diabetes, osteoporosis, cardiovascular disease, dyslipidemia, obesity, metabolic syndrome and, consequently, with an increased risk of kidney stone formation, which, in turn, can lead to chronic kidney disease and end-stage renal disease.[34]

Therefore, some general dietary and lifestyle recommendations should be suggested not only to stone patients but to all individuals as well, to reduce the risk of urinary stone formation and other undesirable health consequences due to the prolonged indoor stay during the pandemic.

How do we Recover Stone Services in the Post-pandemic Era?

COVID-19 will be around for the foreseeable future and infection rates may fluctuate as public health measures relax. This scenario will test the ability of all health providers that are forced to concentrate the majority of resources to diagnose and treat this huge new subset of patients temporarily suspending elective scheduled operations.

As such, a significant backlog of surgical work is being created in addition to those patients on waiting lists before the present crisis.

On the horizon, there is a need to plan for resuming the normal elective stone surgery in the post-COVID era.

Hospitals must keep a clear record of all surgery that is being deferred and identify subgroups of surgical priorities, as for the de-escalation phase.[35]

This will also allow for a correct prioritization of cases when surgical activity will progressively return back to normality.

It is of paramount importance to restore patient confidence in a safe hospital guaranteeing a COVID-free unit.[36]

From a clinical point of view, all the endourologists should be prepared to cope with more complicated and challenging cases which have been postponed because of lower surgical priority; in addition, a significant increase in the waiting list should be anticipated and communicated to the stone patients who are expecting to be operated on immediately during the reopening phase.

Patients with ureteral stents, for example, along with the possible negative impact on quality of life, may develop stent encrustation, pain, haematuria, severe urinary infections in this scenario with a high probability of progressive worsening over time.[37]

Moreover, although it is reasonable that at this moment, the majority of resources are targeted to the COVID-19 outbreak, there is the risk that once the pandemic is controlled the global economy and healthcare systems will be overloaded and budgets downsized.

In this general scenario, stone disease will further increase the socio-economical burden with an increased number of septic patients requiring an Intensive Care Unit stay together with increases in patients on dialysis or needing transplantations because of an inadequate selection during the outbreak.

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