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Table of Contents
Year : 2022  |  Volume : 33  |  Issue : 1  |  Page : 30-34

Primary ureteroscopy for diagnosing and treating acute urolithiasis during the COVID-19 pandemic: Quality and cost benefits

1 Urology Department, Glangwili General Hospital, Wales
2 Urology Department, Medway Maritime Hospital, Kent, UK

Date of Submission19-Jun-2021
Date of Decision29-Jul-2021
Date of Acceptance25-Aug-2021
Date of Web Publication02-Mar-2022

Correspondence Address:
Mr. Mudassir Maqbool Wani
Urology Trainee, Glangwili Hospital, 9 St Christophers Quarter, Swansea, SA1 1UA
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/UROS.UROS_91_21

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Purpose: The purpose of this study was to investigate the management of acute urolithiasis during index admission by primary ureteroscopy (P-URS) during coronavirus disease-2019 (COVID-19) pandemic. With the rise in prevalence of urolithiasis, the focus has shifted to manage patients presenting with acute ureteric colic during their first admission rather than using temporary measures such as emergency stenting (ES) or nephrostomies which are followed by deferred ureteroscopic procedures Deferred Ureteroscopy (D-URS). We compared the results of ES with P-URS procedures in terms of quality and cost benefits during COVID-19 pandemic. Materials and Methods: Data were collected prospectively from April 2020 to March 2021 for all emergency urolithiasis procedures performed including ES and P-URS. The quality assessment was based in relation to patient factors including the number of procedures per patient, number of days spent at hospital, number of days off work, and expertise of person operating. Cost analysis included theater expenses, hospital stay charges, and loss of working days. Results: This study revealed that the average stay of patients on index admission who had an ES was 1.35 days compared to 1.78 days in patients who underwent P-URS. Patients who had ES had to undergo D-URS and spent another average of 1.5 days in the hospital. Overall, additional expenditure in patients who did not undergo primary ureterorenoscopy was on an average in the range of £1800 (excluding loss of work for patients, who needed to return for multiple procedures). Conclusion: We conclude that the approach of P-URS and management of stones in index admission is very effective in both improving quality of patients (during the COVID-19 pandemic) and bringing down cost expenditure effectively.

Keywords: Coronavirus disease-2019, primary ureteroscopy, stenting, urolithiasis

How to cite this article:
Wani MM, Sheikh IM, Marsh H, Sheriff M, Bhat Z, Mullighan J. Primary ureteroscopy for diagnosing and treating acute urolithiasis during the COVID-19 pandemic: Quality and cost benefits. Urol Sci 2022;33:30-4

How to cite this URL:
Wani MM, Sheikh IM, Marsh H, Sheriff M, Bhat Z, Mullighan J. Primary ureteroscopy for diagnosing and treating acute urolithiasis during the COVID-19 pandemic: Quality and cost benefits. Urol Sci [serial online] 2022 [cited 2023 Jun 1];33:30-4. Available from: https://www.e-urol-sci.com/text.asp?2022/33/1/30/338939

  Introduction Top

In late December 2019, several cases of pneumonia of unknown origin were reported from China, which was announced to be caused by a novel coronavirus in early January 2020. The virus was later classified as severe acute respiratory syndrome coronavirus-2 and defined as the causal agent of coronavirus disease-2019 (COVID-19). Despite massive attempts to contain the disease in China, the virus spread globally, and COVID-19 was declared a pandemic by the World Health Organization (WHO) in March 2020.[1]

COVID-19 is arguably the greatest challenge facing health-care systems worldwide. Despite unprecedented measures, there has been an expected surge of patients within a short period. The health-care system has been under tremendous pressure globally, resulting in burnout in health-care workers related to the massive increase in the number of patients beyond the capacity of the health-care systems and the increased risk of infection among the medical workforce.[2]

The COVID-19 pandemic poses a threat to the optimal and safe surgical management of patients. Following the WHO declaration of the pandemic, the United States Surgeon General advised the cancelation of all elective surgeries in hospitals to prevent the spread of the virus.[3] However, the American College of Surgeons later advised prioritizing surgical resources.[4] In addition, the Royal College of Surgeons of England advises stratifying surgical procedures during the pandemic.[5] The guidance advised that prioritizing surgery for patients should be according to a specific classification [Table 1]. The categorization of patients helps managers plan the allocation of resources, allows surgeons to appreciate the needs of other surgical specialties, and facilitates the development of regional surgical networks to sustain the delivery of surgery timely.[5]
Table 1: The Royal College Surgeons of England stratification of patients for surgery during coronavirus disease

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Like any other surgical specialty, urological procedures were also delayed and canceled. Among noncancer urological procedures, during the pandemic, acute urolithiasis presented a challenge as it could be managed by primary ureteroscopy (P-URS) or following temporary measures, such as emergency stenting (ES) or nephrostomies, which are followed by deferred/delayed ureteroscopic procedures (D-URS).

We had conducted a previous audit in 2019 to look into ES in acute urolithiasis and evaluate getting it right the first time, a UK government initiative. The recommendations had been made to perform P-URS as index procedures for acute urolithiasis (before the COVID pandemic). We implemented changes from primary audit and the practice from routine ES to P-URS. The data were collected prospectively for all procedures performed for acute urolithiasis in our hospital, Medway Maritime Trust, Kent, United Kingdom. The primary aim was to look at the quality and cost advantages of P-URS compared with ES during the COVID-19 pandemic. The secondary aim was to compare complications and procedural issues.

  Materials and Methods Top

This study was registered in the Medway Maritime Hospital, Kent, UK, as a quality improvement project. The hospital's ethical committee approved it under reg. No 1920.206N, dated May 25, 2020, and extended from June 2020 to March 2021. Data were collected prospectively from emergency theater systems (CEPOD Register), followed by confirmation from the hospital's business intelligence department. In addition, all patient records (admission/procedure details) were reviewed by two authors through electronic discharges, outpatient letters, and imaging software (PACS).

Inclusion criteria (patients undergoing surgical intervention ES/P-URS):

  1. Patients having one or more clinical indications, such as pain, sepsis, impaired renal function, or unrelieved obstruction
  2. Patients decided and consented to a stent/ureterorenoscopy (URS) procedure.

Exclusion criteria included:

  1. Patients having stent insertion unrelated to urolithiasis
  2. Patients opting for conservative/other treatment modalities, such as extracorporeal shock wave lithotripsy (ESWL)
  3. For P-URS, patients with renal/pelvi-ureteric junction and upper ureteric stones were excluded due to the nonavailability of a flexible ureteroscope in emergency theaters.

Summarizing the surgical pathway followed after the decision to surgically intervene is given in [Figure 1]. All patients whether they underwent ES or P-URS were tested for COVID-19. If a test was negative, they would be operated in theaters designated as “Green” and later managed in designated “Green Zone” surgical wards. However, for positive patients, the surgical procedure was conducted in theaters designated as “Red” and managed postoperatively in designated “Red Zone” surgical wards. Furthermore, all inpatients were tested if they became symptomatic or routinely after 3 days if they remained admitted. In our series, nine patients were positive at the time of surgical intervention. However, since most patients were discharged within 1–2 days, we do not know exactly how many became symptomatic later.
Figure 1: Pathway for primary ureteroscopy group

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It is important to understand that patients who had ES rather than P-URS usually had to wait for 4–6 weeks for D-URS; however, this period got prolonged as routine surgeries were canceled due to the COVID-19 pandemic.

The quality evaluation included the number of hospital admissions/procedures, hospital stay days, and complications in either group. It is necessary to mention that ES patients had to return to the hospital for further procedures, and patients were often not keen as hospitals had an extremely high number of patients with COVID-19. Cost evaluation included theater expenses, hospital stay charges, and loss of working days. Loss of working days was taken as the number of days the patient was in the hospital, excluding days spent at home after the procedure, which can differ among patients.

  Results Top

During the data collection period, 86 patients met the criteria for surgical intervention because of acute urolithiasis. Fifty-four patients were eligible for P-URS, and 32 were eligible for ES. However, out of the 54 patients planned for P-URS, eight had ES performed due to the nonavailability of trained theater staff on weekends. In the end, 54 patients underwent P-URS. Out of these, 34 patients had a ureteric stent (without extraction strings) inserted, 12 patients had stents with extraction strings, and eight patients had no stent placed after the procedure [Table 2].
Table 2: Comparative analysis of procedure-related outcomes

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Quality analysis revealed that if patients had ES, they stayed in the hospital for an average of 1.35 days, had D-URS afterward, and had to stay for another 1.5 days after that procedure. If the patient had a ureteric stent (without extraction strings) inserted after the procedure, they had to revisit the hospital for its removal. On average, patients in the ES group spent 3.85 days in the hospital and had to be in the hospital at least three times.

In contrast, in the P-URS group, patient's total stay in the hospital was 1.78 days, and those with ureteric stents (without extraction strings) had to return to the hospital for stent removal. On average, patients in the P-URS group spent 2.78 days in the hospital. Thus, in the P-URS group, those with ureteric stents (without extraction strings) had to be in the hospital at least twice [Table 3]. If the patient in the P-URS group had a stent with extraction strings, they had no need to return to the hospital.
Table 3: Comparative analysis of quality-related outcomes

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Cost analysis revealed that, in the ES group, if patients having no comorbidities had all three procedures performed, total expenditure (theater and hospital) cost about £4740. Patient loss during hospital stay was around £375. In contrast, in the P-URS group, if the patient had two procedures, the total expenditure (theater and hospital) cost about £3412. Patient loss during hospital stay was around £271[Table 4], [Figure 2].
Table 4: Comparative analysis of cost-related outcomes (patients with no comorbidities)

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Figure 2: Estimated cost differences (average in pounds)

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Major complications in both the groups (ES vs. P-URS) included urosepsis (4.8% vs. 4.16%), urinary retention (2.4% vs. 1.4%), and acute pyelonephritis (1.2% vs. 1.4%).

  Discussion Top

Urolithiasis is a common clinical entity in urological science with a lifetime prevalence of around 14%,[6] having a wide spectrum of asymptomatic clinical presentations, both acute and chronic. Among acute presentations, renal/ureteric colic is common, and it is characterized by acute onset of flank pain, often with radiation to the groin, and may be associated with hematuria, either visible or nonvisible. Although the number of patients in the emergency department presenting with acute renal colic varies depending on geography, studies from the US have revealed that it ranges from 6% to 9%, out of which 12% require admission after initial assessment.[7] Furthermore, urinary tract stones presenting in an emergency can be managed by emergency temporizing measures (stenting or percutaneous nephrostomy tube insertion) or definitive treatments, such as URS, percutaneous nephrolithotomy, and shock wave lithotripsy (ESWL). URS has become a routineprocedure due to its widened indications, endoscopic nature, relatively short operating time due to the of instruments, and minimal risk of complications, including bleeding.[8],[9]

The mean age of patients in our study was around 54.5 years, similar to previous studies in which the most common age group is 50–59 years.[10] The ratio of the male/female population in our study was about 2:1, also reflected in previous studies.[10] Men are at higher risk for kidney stones overall because of a greater tendency for the urine to be oversaturated with calcium oxalate.[11],[12] Complications associated with ES include urinary tract infection, malposition and migration, inadequate relief of obstruction, encrustation, stent fracture, ureteral erosion or fistulization, and the forgotten stent.[13] Complications in P-URS/D-URS are established, particularly sepsis, in around 4.3% of patients who undergo elective URS.[14] Our study found that sepsis was in the range of 4.1%–4.8%, followed by urinary retention, which was in the range of 1.4%–2.4%. We also observed that patients who had ES and had to wait for ureteroscopy had stent symptoms, which varied depending on the severity of symptoms. This was the worst-case scenario for patients as elective surgeries were put on hold. However, this was not a major issue for patients who underwent P-URS as they had their stents removed within 1–2 weeks.

Patients who underwent ES had to visit the hospital at least two more times, even during the peak of the pandemic, first for D-URS and second for stent removal if reinserted during the definitive procedure. Thus, quality wise, patients had to have three procedures required for stone management even during the pandemic. This implies more expenses involved for hospitals and more days of work loss for the patient. However, patients who had P-URS received definitive treatment during index admission and would return to the hospital if a stent was inserted during P-URS. A similar study had revealed that patients undergoing ureteric stenting take significantly longer to become stone free, leading to increased hospital readmissions, potentially increased morbidity, and inevitably greater cost implications. In the study, patients who underwent P-URS became stone-free significantly quicker than ES (2.5 days vs. 61.9 days).[15]

We also observed that using stents with extraction strings after P-URS or D-URS helps reduce cost as the patient does not need any further cystoscopy to remove the stent. It also improves the quality of life as the patient can remove it independently without the need to return to the hospital. In addition, a recent systemic review has suggested that stents with extraction strings are easy for patient self-removal and can reduce the stent dwell time for patients; thus, reducing the duration of morbidity and physical and financial burden.[16]

This study reveals that if facilities are available for all patients presenting with acute urolithiasis and require surgical intervention, they should be offered P-URS as it is safe and has quality and cost advantages rather than a temporary emergency measure such as ES/nephrostomy, particularly in situations, such as COVID-19 pandemic. However, this process is challenging, needs support from hospital authorities, training of teams, and availability of expert staff.

Our study has many limitations. First, it is neither randomized nor completely prospective. Second, due to the COVID-19 pandemic, the selection of the pathway was not always straightforward and had to be altered, as has been discussed in the results already. Third, the procedures were not performed by a single surgeon but by surgeons with different levels of expertise. Finally, the pathway suggested in this study represents acute urolithiasis management during the initial phase of the COVID pandemic. Since more understanding of this disease and its prevention (vaccination) is evolving, these pathways may need to be changed or altered.

  Conclusion Top

We conclude that all patients presenting with urolithiasis should be offered P-URS if the hospital has facilities and staff (doctors and trained urological nurses). The procedure is safe and highly effective in improving quality for patients and bringing down expenses. However, notably, such pathways need to be flexible and may need to be changed or modified as we better understand COVID pathogenesis and its management.

Financial support and sponsorship


Conflicts of interest

There are no conflicts of interest.

  References Top

Ludwig S, Zarbock A. Coronaviruses and SARS-CoV-2: A brief overview. Anesth Analg 2020;131:93-6.  Back to cited text no. 1
Adams JG, Walls RM. Supporting the health care workforce during the COVID-19 global epidemic. JAMA 2020;323:1439-40.  Back to cited text no. 2
Health Leaders Surgeon General Urges Providers to 'Consider Stopping Elective Surgeries.' Hospitals Push Back. Availablefrom: https://www.healthleadersmedia.com/clinical-care/surgeon-general-urges-providers-consider-stopping-elective-surgeries-hospitals-push. [Last accessed on 2021 Sep 18].  Back to cited text no. 3
Stahel PF. How to risk-stratify elective surgery during the COVID-19 pandemic? Patient Saf Surg 2020;14:8.  Back to cited text no. 4
Clinical Guide to Surgical Prioritisation during the Coronavirus Pandemic. Available from: https://www.england.nhs.uk/coronavirus/wp-content/uploads/sites/52/2020/03/C0221-specialty-guide-surgical-prioritisation-v1.pdf. [Last accessed on 2020 Nov 12].   Back to cited text no. 5
Rukin NJ, Siddiqui ZA, Chedgy EC, Somani BK. Trends in upper tract stone disease in England: Evidence from the hospital episodes statistics database. Urol Int 2017;98:391-6.  Back to cited text no. 6
Ghani KR, Roghmann F, Sammon JD, Trudeau V, Sukumar S, Rahbar H, et al. Emergency department visits in the United States for upper urinary tract stones: Trends in hospitalization and charges. J Urol 2014;191:90-6.  Back to cited text no. 7
Geraghty RM, Jones P, Somani BK. Worldwide trends of urinary stone disease treatment over the last two decades: A systematic review. J Endourol 2017;31:547-56.  Back to cited text no. 8
Geavlete P, Multescu R, Geavlete B. Pushing the boundaries of ureteroscopy: Current status and future perspectives. Nat Rev Urol 2014;11:373-82.  Back to cited text no. 9
Lieske JC, Rule AD, Krambeck AE, Williams JC, Bergstralh EJ, Mehta RA, et al. Stone composition as a function of age and sex. Clin J Am Soc Nephrol 2014;9:2141-6.  Back to cited text no. 10
Lieske JC, Peña de la Vega LS, Slezak JM, Bergstralh EJ, Leibson CL, Ho KL, et al. Renal stone epidemiology in Rochester, Minnesota: An update. Kidney Int 2006;69:760-4.  Back to cited text no. 11
Parks JH, Coward M, Coe FL. Correspondence between stone composition and urine supersaturation in nephrolithiasis. Kidney Int 1997;51:894-900.  Back to cited text no. 12
Dyer RB, Chen MY, Zagoria RJ, Regan JD, Hood CG, Kavanagh PV. Complications of ureteral stent placement. Radiographics 2002;22:1005-22.  Back to cited text no. 13
Bloom J, Fox C, Fullerton S, Matthews G, Phillips J. Sepsis after elective ureteroscopy. Can J Urol 2017;24:9017-23.  Back to cited text no. 14
Darrad M, Sibartie T, Inglis J, Rukin N. Is acute ureteroscopy for painful ureteric colic cost effective and beneficial for patients? A cost-analysis. J Clin Urol 2017;10:17-20.  Back to cited text no. 15
Oliver R, Wells H, Traxer O, Knoll T, Aboumarzouk O, Biyani CS, et al. Ureteric stents on extraction strings: A systematic review of literature. Urolithiasis 2018;46:129-36.  Back to cited text no. 16


  [Figure 1], [Figure 2]

  [Table 1], [Table 2], [Table 3], [Table 4]


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