Scotland KB. et al., 2021: Consensus Statement on Urinary Stone Treatment During a Pandemic: A Delphi Process from the Endourological Society TOWER Research Initiative.
Scotland KB, Tailly T, Chew BH, Bhojani N, Smith D.
Department of Urology, University of California, Los Angeles, California, USA.
Department of Urology, University Hospital Ghent, Ghent, Belgium.
University of British Columbia, Vancouver, Canada.
Division of Urology, Centre Hospitalier de l'Université de Montréal, Université de Montréal, Montreal, QC, Canada.
Department of Urology, University College Hospital, London, United Kingdom.
Introduction: The novel coronavirus disease (COVID-19) pandemic has had a significant impact on the care of patients with urolithiasis. Recommendations and prioritization of endourologic surgical procedures vary among regions, and a comprehensive overall international directive is needed. We used the Delphi method to obtain international consensus on managing urolithiasis patients during the pandemic. Methods: A three-round Delphi process was used to elicit expert consensus (53 global key opinion leaders within the Endourological Society from 36 countries) on an extensive survey on management of endourologic patients in a pandemic. Questions addressed general management, inpatient and outpatient procedures, clinic visits, follow-up care, and best practices for suspension and resumption of routine care. Results: Consensus was achieved in 64/84 (76%) questions. Key consensus findings included the following: consultations should be delivered remotely when possible. Invasive surgical procedures for urolithiasis patients should be reserved for high-risk situations (infection, renal failure, etc.). To prevent aerosolization, spinal anesthesia is preferred over general, whenever feasible. Treatment of asymptomatic renal stones should be deferred. Primary definitive treatment of obstructing or symptomatic stones (both renal and ureteral) is preferred over temporizing drainage. Extracorporeal shockwave lithotripsy should be continued for obstructive ureteral stones. There was consensus on treatment modalities and drainage strategies depending on location and size of the stone. Conclusion: International endourologist members of the Endourological Society participated in this Delphi initiative to provide expert consensus on management of urolithiasis during a pandemic. These results can be applied currently and during a future pandemic.
TOWER Initiative.J Endourol. 2022 Mar;36(3):335-344. doi: 10.1089/end.2021.0477. PMID: 35019782
This report summarizes consensus on how patients with stone disease best should be managed during the COVID-19 pandemic.
Below are some important points extracted from the article:
1. Remote out-patient consultations should be preferred. In case of face-to-face consultations special precautions are necessary.
2. Observation only, should be applied for asymptomatic stones up to 10 mm
3. SWL is recommended for symptomatic obstructive stones.
4. For ureteral stones definitive treatment is preferred to stenting.
5. When URS is considered, spinal anaesthesia is recommended for treating distal ureteral stones.
6. For URS of stones in other parts of the ureter general anaesthesia should be given. (My personal choice would be SWL with analgesics only, to avoid exposing personnel to virus-aerosol).
7. For renal stones 11-20 mm, fURS is recommended and for stones > 20 mm PCNL. (I would suggest SWL for the smaller stones)
The article contains a list of recommendations to be applied in pandemics like COVID-19. That list should be studied by urologists and surgeons.
My own comment, however, is that SWL is recommended surprisingly seldom under such circumstances, despite its favourable properties to avoid anaesthesia and the risk of aerosol spreading of virus. Moreover, SWL does not require occupation of beds because it is an outpatient procedure.
Another point is that when delayed treatment finally must be considered in many accumulated patients, it is favourable to use SWL which is a treatment method without need of general or regional anaesthesia and without need of operating theatres. Such facilities should be reserved for patients who cannot be treated without anaesthesia and operating theatre service.