Prospective comparison of extracorporeal shock wave lithotripsy versus flexible ureterorenoscopy in patients with non-lower pole kidney stones under the COVID-19 pandemic.

Both shock wave lithotripsy (SWL) and flexible ureterorenoscopy (F-URS) are recommended as the first choice for non-lower pole kidney stones. Therefore, we conducted a prospective study to evaluate the efficacy, safety, and cost of SWL versus F-URS in patients with solitary non-lower pole kidney stones ≤ 20 mm under the COVID-19 pandemic. This prospective study was conducted in a tertiary hospital from June 2020 to April 2022. Patients who underwent lithotripsy (SWL or F-URS) for non-lower pole kidney stones were enrolled in this study. The stone-free rate (SFR), retreatment rate, complications, and cost were recorded. Propensity score-matched (PSM) analysis was performed. A total of 699 patients were finally included, of which 81.3% (568) were treated with SWL and 18.7% (131) underwent F-URS. After PSM, SWL showed equivalent SFR (87.9% vs. 91.1%, P = 0.323), retreatment rate (8.6% vs. 4.8%, P = 0.169), and adjunctive procedure (2.6% vs. 4.9%, P = 0.385) compared with F-URS. Complications were scarce and also comparable between SWL and F-URS (6.0% vs 7.7%, P > 0.05), while the incidence of ureteral perforation was higher in the F-URS group compared with the SWL group (1.5% vs 0%, P = 0.008). The hospital stay was significantly shorter (1 day vs 2 days, P < 0.001), and the cost was considerably less (1200 vs 30,083, P < 0.001) in the SWL group compared with the F-URS group. This prospective cohort demonstrated that SWL had equivalent efficacy with more safety and cost benefits than F-URS in treating patients with solitary non-lower pole kidney stones ≤ 20 mm. During the COVID-19 pandemic, SWL may have benefits in preserving hospital resources and limiting opportunity for virus transmission, compared to URS. These findings may guide clinical practice.

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.

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.

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.

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 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).

Cross-sectional survey of patients awaiting nephrolithiasis surgery during the covid-19 pandemic onset: A multi-center study from the registry for stones of the kidney & ureter group

Introduction & Objective: The Coronavirus pandemic led to wide-spread reductions in surgical volume. Many patients were hesitant to undergo surgery, despite appropriate hospital precautions. Kidney stone patients pending surgical intervention have distinct risks associated with surgical delay including pain, infection, and loss of renal function. It is important to understand the risks of surgical delay during the pandemic and to better understand patient concerns and preferences for undergoing surgery. Methods: A prospective, multi-institutional patient survey during April and May 2020 was performed. Nephrolithiasis patients pending stone removal surgery including ureteroscopy, shockwave lithotripsy, percutaneous nephrolithotomy, and nephrectomy were interviewed at clinical encounters regarding their symptoms, unplanned clinical events, presence of nephrostomy tubes /double J stents, concerns and reassurances for coming to the hospital, and willingness to undergo surgery. The association of patient demographics, stone burden, renal function, stonerelated symptoms, and COVID risk factors with willingness to undergo surgery, and concerns for contracting COVID were examined. Results: 142 patients pending stone surgery completed surveys, with 66% willing to proceed with surgery, while 34% requested to delay. There was no statistical difference in patients willing versus unwilling to proceed with surgery, with regards to patient demographics, type of surgical procedure, stone burden, stonerelated symptoms, renal function compromise, presence of hydronephrosis, unplanned clinical events, or COVID risk factors. Those willing to proceed were more likely to have a ureteral stone (32% vs 15%, p = 0.03) or have a ureteral stent or nephrostomy tube in place (35% vs 6%, p < 0.01). Willingness to proceed with surgery was inversely correlated with COVID19 concerns. COVID19 concern was not impacted by age, sex, clinical site, distance to hospital, or COVID 19 risk factors. Conclusions: Kidney stone patients pending surgical treatment weremore willing to proceed with surgery based on the presence of a ureteral stone, upper urinary tract drainage tube, or low concern for COVID. Patient demographic, symptoms, kidney function, and other stone risk factors were not associated with willingness for surgery. Patients that are hesitant to proceed with surgery, despite appropriate hospital precautions should be educated appropriately regarding their risks with regards to COVID and nephrolithiasis.