Grand Journal of Urology
E-ISSN : 2757-7163

Management of Ureteral Stones During Covid-19 Outbreak
COVID-19 pandemic is the newest and most serious health threat worldwide. Medical and surgical priorities have been dramatically changed during this outbreak. Cancellation or postponement was fulfilled or considered for whole outpatient and some severe conditions to protect the facilities and resources for urgent healthcare. Most hospitals accepted individuals who have COVID-19 in affected countries. The COVID-19 pandemic has changed the patient admission process and healthcare strategies at numerous emergency departments across Turkey, and the possible effects of this alteration on people are still unclear. In upcoming periods, the healthcare workers, including urologists, possibly would be facing increasingly complex challenges, which could, in turn, make them develop various protection modalities to provide sufficient defense against this insult when dealing with the COVID-19 patients. 
Besides some modifications seen in the general medical approach, the treatment options applied in urinary stone cases have also significantly changed during the pandemic. Hence, the optimal anesthesia methods are still unknown. Under the current outbreak and COVID-19 pandemic scenario, hospitals should prioritized patients affected by lithiasis into low, intermediate, high risk, and emergency categories (according to the priority classification of the European Urology Guidelines Office Rapid Reaction Group Urolithiasis Guidelines Panel) to decide their delay and save resources, healthcare personnel, beds, and ventilators. However, patients with potentially serious septic complications need emergency interventions. The possibility of performing or restarting elective activity depends on local conditions, the availability of beds and ventilators, and the implementation of screening protocols in the context of the COVID-19 pandemic. Emergency intervention is inevitable if any alarming indication exists. Emergency cases tend to have a higher incidence of complications with the initiation of the COVID-19 outbreak when compared with before.
In a non-urgent urolithiasis condition, endo-urologists should make a rational treatment decision to prioritize the urolithiasis treatment. They should also compare the benefits and risks before the intervention. Because of the fear of being infected with COVID-19, patients with nephrolithiasis who stay at home instead of admitting to a medical center may suffer serious complications such as obstructive uropathy, deterioration of renal functions, sepsis, and even mortality. Although the number of emergency admissions related to stone disease cases has gradually decreased, some severe findings such as leukocytosis, higher creatinine levels, increased grade 3 and 4 hydronephroses, and complications tend to be seen more frequently when compared to the periods before the pandemics. Some endo-urologists prefer definitive stone treatment over temporary drainage to reduce the number of emergency room visits and hospital admissions, except if the infection is present or staged treatment is planned. Several clinical scenarios of non-emergency and non-urgent urinary stones are current; thus, endo-urologists should appropriately weigh patients' risk and surgery benefits to decide the proper intervention time. If the risks are more than the benefits to the patient, it would be better to postpone the surgery. A significant reduction in the global number of patients admitted to Emergency Department (ED) for urolithiasis was noted. Moreover, regarding the choice of treatment of hospitalized patients, a significant increase of stone removal procedures versus urinary drainage was reported in 2020. Renal colic should be managed with expulsive medical therapy and proper pain control with a close follow-up just in case it becomes an emergency. Indwelling JJ stent removal or exchange is a matter of debate: Some endo-urologists recommend removing, while the others recommend postponing it. 
In most COVID-19 infected patients with urolithiasis, extracorporeal shock wave lithotripsy (ESWL) should be kept in mind as a treatment option for the patient who doesn't require active stone removal. While patient and health care worker interaction kept minimum, it also represents the least morbid treatment and can generally be performed without a ureteric stent. Physicians can also prefer medical expulsive therapy (MET) as a treatment option for patients with distal ureteral stone, which shows highly effectiveness against distal 5-10 mm urinary stones. If a patient requires an active surgical approach, persistent obstruction, renal failure, and refractory pain can be safely and effectively treated by endoscopic ureteral stone treatment.
During the COVID-19 pandemic, there has been a significant reduction of emergency admissions for urolithiasis. Patients admitted to ED had more complications, more frequently need hospitalization, and early stone removal was preferred over urinary drainage only in clinical management. All urologists should be aware that they could face an increased number of admissions for urolithiasis and manage more complicated cases in the following months. Delaying urolithiasis surgery and increasing waiting lists will have consequences and will require considerable additional effort. Teleconsultation may help guide these patients, reduce visits and unnecessary exposure.