Letter
to
the
Editor
UrolithiasisPracticePatternsFollowingtheCOVID-19
Pandemic:OverviewfromtheEULISCollaborative
ResearchWorkingGroup
COVID-19wasfirstreportedasanovelpulmonaryinfection
inDecember2019[1].Apartfrombeingapotentiallylethal
condition,COVID-19isalsoaffectinghealthcarestrategies
for othermedicalconditions. Ficarraetal [2]have made
suggestions regarding urological surgeries during the
COVID-19pandemic.However, theauthorsfocusedon all
urologicalpathologiesandreportedinformationfromItaly,
acountrythatseemedtobetheepicenterofthepandemic
inEurope[2].Therefore,wesoughttoobtainanup-to-date
perspectiveonhowtheroutinepracticepatternsofexpert
Europeanendourologistschanged(oradapted)duringthe
COVID-19 pandemic via a survey. By focusing on expert
experiencecomingfromthefield,weaimedtoprovidean
algorithm to guide the management of urinary stone
disease during this unprecedentedtime of extraordinary
stressontheglobalendourologycommunity.
An online survey composed of 31 questions
(Supple-mentary material) using the web-based Survey-Monkey
system(PaloAlto,CA)wascirculatedprimarilytoauthors
whowereintheEULISworkinggroups,whosemainareasof
expertisewasurinarystonedisease,andwhohad
contrib-utedtotheliteraturetodate.Among98expertsapproached,
60physicians(61.2%)responded.
The distribution of the countries involved is given in
Table1.Atthetimeofsurveycompletion,thefirstCOVID-19
pandemic case was reported >21 d previously in the
countryof67.2%oftherespondentsandbetween7and21d
previously in the country of 32.8% of the respondents
(Table 1). While all responding experts experienced a
change of at least 25% in routine clinical practice, 49%
reportedachangeof>90%in(Fig.1A).Amongtheexperts,
72.3%usedtelemedicineduringthepandemic(Fig.1B).
The majority of the experts (89.4%) tendedto change
their treatment strategy for an emergency patient with
COVID-19 by planning anelective intervention following
drainageofthecollectingsystem;however, 10.6%continued
toperformstoneremovalproceduresinthesecases.Some
43%of respondents continued to use a surgical mask as
beforethepandemic,whereas17%didnotperformsurgery.
Regardingeyeprotection,25.5%startedusinggoggles,21.3%
werealreadyusinggoggles,and34%didnotshifttotheuse
ofgogglesaspartoftheirpandemicresponse.
Amongtherespondents,55.3%and39.8%changedtheir
elective surgicaltreatment approachafterCOVID-19bya
rate of 90–100% and 75–89%, respectively. Only 6.4%
continuedasbeforethepandemic.Fromananesthesiology
point ofview, routinethorax computedtomography (CT)
wasrequested24hbeforesurgeryby27.7%oftheexperts,
whereas,61.7%requestedthoraxCTinthecaseofCOVID-19
suspicion. Some34%of the respondents preferred spinal
anesthesia instead of general anesthesia, whereas 17%
continued with spinal anesthesia as used before the
pandemic (Fig. 1C), possibly because of the well-known
safety of spinal anesthesia in stone surgery [3]. Unless
contraindicated,we thinkthatendourologists mayprefer
regional anesthesia during the COVID-19 pandemic,
dependingontheirhospitalconditions.
Nearlyhalfoftherespondents(48.9%)statedthat
COVID-19 patients havebeenhospitalized in their departments,
withapproximately40%takinganactiveroleinevaluating
respiratorysymptomsinthesepatients(Fig.1D).Therefore,
itisobviousthatalthoughnotspecializinginthe
manage-mentofcontagiousdiseases,allhealthcarestaffincluding
doctorsspecializinginotherdisciplineshavebeenobliged
to deal with the pandemic. More than 85% of the
participantsreportedadecreaseof>50%intheworkload
ofoutpatientclinics.Routinetreatmentprotocolsforstone
management were reported as altered by 91.3% of the
experts. Changes in routine treatment protocols were
furtherinvestigatedinthequestionnaireforcertainclinical
situations.Formanagementofstonesof<2cmand2–3cm
in size, 31.9% and27.6% of the participants, respectively,
statedthattheywouldpreferaconservativeapproachuntil
thepandemicsettles.Inaddition,approximatelytwo-thirds
stated thatthey wouldpostponeanyauxiliary procedure
becauseoftheCOVID-19pandemicand51%statedthatthey
woulddischargepatients onthesamedayorwithin 24h
postoperatively.
Another important aspect is emergency department
admissionofstonepatients.Emergencyphysicians
encoun-terstonepatientswithmoresevereconditionssuchascolic
pain, acute renal failure, and pyelonephritis. The survey
outlinedthatemergencydepartmentmanagementofstone
patientswasalsoalteredinmorethan90%ofcasesduring
EUROPEANUROLOGY78(2020)E21–E24
a v ai l a b l e a t w w w . s c i e n c e d i r e c t . c o m
j o u r n al h o m e p a g e : w w w . e u r o p e an u r o l o g y . c o m
https://doi.org/10.1016/j.eururo.2020.04.057
Fig.1–PracticepatternsamongexpertendourologistsduringtheCOVID-19pandemic.
Table1–Dataforthe60participantsfrom20differentcountriesinterestedinurolithiasiswhowereincludedinthestudysurvey.a
Country Region(s) Totalcases Timebetween
officiallyreported firstcaseandresponse
tothesurvey(d)
Totaldeaths duetoCOVID-19
Timebetween officiallyreportedfirst 10deathsandresponse
tothesurvey(d)
Azerbaijan Baku 298 31 5 Notapplicable
Austria Vienna,Salzburg 10182 35 128 9
Belgium Gent 12775 56 705 15
Bulgaria Sofia 399 24 8 Notapplicable
Czechia SouthBohemia 3308 30 31 3
Denmark Fredericia,Copenhagen 2860 34 90 10
France Paris 51477 69 3523 24
Georgia Tbilisi 115 34 0 Notapplicable
Germany Baden-Württemberg,Bavaria,
Niedersachsen
67366 66 775 16
Greece Patras,NortheasternGreece 1314 34 49 11
Italy Bergamo,Lombardy,Rome,
Milan,Naples
105792 63 12428 35
NorthMacedonia Skopje 329 34 9 Notapplicable
Poland Malopolska 2311 28 33 7
Romania Bucharest 2245 33 69 7
Russia SaintPetersburg 2337 60 17 0
Serbia Belgrade 900 25 13 2
Spain Barcelona,Valladolid,Catalonia,
ComunidadValenciana,Madrid,
Alicante,Granada
94417 62 8464 24
Sweden Stockholm 4435 61 180 13
Turkey Ankara,Istanbul,Konya 13531 20 214 10
UK London,Manchester,Cambridgeshire 25150 62 1789 20
a Datainthetablewerecollectedfromthewebsiteswww.who.int/emergencies/diseases/novel-coronavirus-2019,www.worldometers.info/coronavirus,and
https://ourworldindata.org/coronavirususinginformationupdatedonMarch31,2020.
EUROPEANUROLOGY78(2020)E21–E24
thisperiod.Althoughtheapproachtostonepatientsinthe
emergencydepartmentwasthesameasbeforeaccordingto
6.4% of the experts, 55.3% began to accept cases from
anotherCOVID-19areaatthesameemergencydepartment,
25.5% accepted emergent urolithiasis cases in a newly
organizedspaceinthehospital,and10.6%didnotaccept
COVID-19casesatall.Some2%oftherespondentsreferred
emergenturolithiasiscasestootherspecializedCOVID-19
centers.While timely managementof these cases in the
emergency department is crucial, clinical controversies
ariseifthesepatientsarealsosuspiciousfor COVID-19.A
possiblescenarioofapatientpresentingtotheemergency
departmentwithseverecolicpain,fever,andcoughwould
bearealdilemmaforphysicians.Inthesurvey,nearly90%of
the participants stated that they would change the
treatmentstrategyforanemergencycasewhenthepatient
ispositiveforCOVID-19.Therefore,clinicalalgorithmsfor
cases presenting with renal obstruction, urinary tract
infection, and acute renal failure would be helpful
(Fig. 2). Changes in sterilization strategies during the
COVID-19 pandemic were also included inthe
question-naire: only 34.8% of the respondents did change their
routinestrategy for sterilization.This may bebecause of
either a lack of knowledge on the risk of urine-based
dissemination of viral RNA or a lack of modification of
sterilization strategies in hospitals in the short time
immediatelyafterthefirstcasereportonCOVID-19.
InmanyEuropeancountries,thepandemicstartedmore
than3wkagoandhasgainedmomentum,andoursurvey
wascarriedoutduringthiscriticalperiod.Whenfacedwith
such an unexpected situation, urologists, like other
physicians, tend to use all of the resources available in
theirweb-basedenvironment,such asEuropean
Associa-tion of Urology COVID-19 resources for urologists, the
American Urological Association coronavirus disease
2019informationcenter,andsocial media.TheCOVID-19
pandemic has led to significant changes in the practice
patternsofendourologistsforthemanagementofurinary
stonedisease.Giventheriskofnovelviralpandemicsinthe
future, the endourology community should be aware of
possiblealterationsinclinicalpractice.Clinicalalgorithms
mayserveasausefulguideinadaptingtothesechangesin
timeandinmanagingpatientswithurinarycalculisafely
andsuccessfully.
Conflictsofinterest:Theauthorshavenothingtodisclose.
AppendixA. Supplementarydata
Supplementary material related to this article can be
found,intheonlineversion,atdoi:https://doi.org/10.1016/j.
eururo.2020.04.057. References
[1]WangD,HuB,HuC,etal.Clinicalcharacteristicsof138hospitalized
patients with 2019 novel coronavirus-infected pneumonia in
Wuhan,China.JAMA2020;323:1061–9.
[2]FicarraV,NovaraG,AbrateA,etal.Urologypracticeduring
COVID-19pandemic.MinervaUrolNefrol2020.http://dx.doi.org/10.23736/
S0393-2249.20.03846-1, [Epub ahead of print] PubMed PMID:
32202401.Mar23.
[3]Zeng G, ZhaoZ,YangF,Zhong W, WuW, ChenW. Retrograde
intrarenalsurgerywithcombinedspinal-epiduralvsgeneral
anes-thesia: a prospective randomized controlled trial. J Endourol
2015;29:401–5.
TzevatTefika
SelcukGuvenb,*
LucaVillac
MehmetIlkerGokced
PanagiotisKallidonise
KremenaPetkovaf
MuratCanKiremitg
MehmetGiraySonmezh
ElisadeLorenzisi
BilalEryildirimj
KemalSaricak
Fig.2–TreatmentalgorithmforurinarystonepatientsduringtheCOVID-19pandemic.UTI=urinarytractinfection;qSOFA=quicksepsis-relatedorgan
failureassessment.
aDepartmentofUrology,IstanbulFacultyofMedicine,IstanbulUniversity,
Istanbul,Turkey
bDepartmentofUrology,SchoolofMedicine,IstanbulMedipolUniversity,
Istanbul,Turkey
cDivisionofExperimentalOncology/UnitofUrology,UrologicalResearch
Institute,IRCCSOspedaleSanRaffaele,Milan,Italy
dDepartmentofUrology,SchoolofMedicine,AnkaraUniversity,Ankara,
Turkey
eDepartmentofUrology,UniversityHospitalofPatras,Patras,Greece fDepartmentofUrologyandNephrology,MilitaryMedicalAcademy,Sofia,
Bulgaria
gDepartmentofUrology,SchoolofMedicine,KoçUniversity,Istanbul,Turkey hDepartmentofUrology,NEÜMeramMedicineFaculty,Konya,Turkey
iDepartmentofUrology,OspedaleMaggiorePoliclinico,Milan,Italy jDepartmentofUrology,HealthSciencesUniversity,Dr.LütfiKirdarTraining
andResearchHospital,Istanbul,Turkey
kDepartmentofUrology,MedicalSchool,BiruniUniversity,Medicana
BahcelievlerHospital,Istanbul,Turkey
*Correspondingauthor.DepartmentofUrology,SchoolofMedicine, IstanbulMedipolUniversity,Istanbul,Turkey. E-mailaddresses:[email protected](S.Guven).
[email protected](S.Guven).
April21,2020
EUROPEANUROLOGY78(2020)E21–E24
