key: cord-0811903-hw4qgcab authors: Demirdogen, Saban Oguz; Cinislioglu, Ahmet Emre; Cinislioglu, Nazan; Altay, Mehmet Sefa; Karabulut, Ibrahim; Polat, Ozkan; Adanur, Senol title: Treatment management of COVID‐19 positive patients with renal colic secondary to distal ureteral stone date: 2021-01-09 journal: Int J Clin Pract DOI: 10.1111/ijcp.13976 sha: 346097a993afdc8c229222adc0204fc5f6f9bd50 doc_id: 811903 cord_uid: hw4qgcab OBJECTIVE: In this study, we aimed to contribute to the literature by sharing and evaluating the clinical characteristics and our treatment and follow‐up approaches in patients in the COVID‐19 positive treatment process who had presented to our hospital's emergency department with a distal ureteral stone and to examine the effects of the pandemic and disease in this group of patients. METHOD: The study included 14 patients infected with COVID‐19 who had presented to the Erzurum City Hospital Emergency Department between August 2020 and December 2020 with the complaint of renal colic in which distal ureteral stones were detected in the tests. The demographic and clinical characteristics of patients, laboratory and radiological examinations, characteristics of ureteral stones, details of treatments applied to patients, treatment procedures of patients who had undergone surgical treatment, patient files, visit and operation notes and the patient discharge reports were retrospectively reviewed and evaluated. RESULTS: The study included 14 patients. The average age of the patients was 35.7 (±14.35). The average stone size was 6.2 (±1.8) mm. Analgesic treatment and MET for distal ureteral stones were begun in 11 (78.6%) of the patients. Pain control was achieved in nine patients (64.2%) with analgesic treatment and MET, and the stone was removed without invasive intervention. Surgical intervention was performed in a total of five patients (35.7%). CONCLUSION: In most COVID‐19 infected patients with renal colic and a distal ureteral stone, results can be obtained using MET. Patients with a distal ureteral stone and persistent renal colic can be safely and effectively treated by endoscopic ureteral stone treatment after taking necessary precautions. Prospective, randomised, and controlled studies are required on this subject. The local ethics committee approved this study with the decision numbered 2020/20-197 and dated 02.11.2020. The study was carried out in accordance with the Helsinki Declaration and written informed consent was obtained from each patient prior to the study. The study included 14 patients infected with COVID-19 who had presented to the Erzurum City Hospital Emergency Department between August 2020 and December 2020 with the complaint of renal colic in which distal ureteral stones were detected in the tests. The demographic and clinical characteristics of patients, laboratory and radiological examinations, the characteristics of the ureteral stones, details of treatments applied to patients, treatment procedures of patients who had undergone surgical treatment, the patient files, visit and operation notes, and the patients' discharge reports were retrospectively reviewed and evaluated. Patients over the age of 18 who had presented to a healthcare institution because of symptoms associated with COVID-19 diagnosed with real-time PCR method by taking nasopharyngeal swabs and under treatment in accordance with the Ministry of Health's national COVID 19 guideline were included in the study. Patients without a nasopharyngeal swab real-time PCR verified COVID-19 diagnosis, patients that did not attend follow-ups, pregnant patients, and patients under 18 years of age were excluded from the study. Routine biochemical tests and complete blood count were ordered for COVID-19 patients who had presented to the emergency department with distal ureteral stone and renal colic. These patients were first evaluated by Urinary System Ultrasonography (USG). In the presence of direct or indirect radiological findings of distal ureteral stones such as stone and hydronephrosis on USG, the diagnosis was made by performing non-contrast-mediated computed tomography (NCCT). After diagnosing the stone, the stones were classified as opaque or non-opaque by kidney-ureter-bladder (KUB) radiography. In the European Association of Urology (EAU) 2020 guideline, it is stated that medical expulsive therapy (MET) can be used in distal ureteral stones without an indication for invasive intervention unless complications such as infection, refractory pain, and impaired renal function develop. 8 In line with the recommendations of the guideline, patients with a stone smaller than 1 cm at presentation whose renal colic could be relieved by paracetamol as an analgesic (1 vial containing 10 mg/ml of infusion solution), who did not require hospitalisation for reasons such as kidney failure or sepsis, were included in a follow-up programme with MET including tamsulosin 0.4 mg a day as an alpha-blocker. In the follow-ups of patients who received MET, history of stone passing, pain relief, no stone being visualised on KUB radiography, and no hydronephrosis on USG under polyclinic conditions, was accepted as stonelessness for opaque stones. In non-opaque stones, history of stone passing, pain relief, and the absence of hydronephrosis on USG under polyclinic conditions were accepted as stonelessness. Urology outpatient clinic control was recommended and planned for all patients in which stonelessness was achieved at the end of the treatment and isolation process for COVID-19. Pain assessment for patients presenting with renal colic was performed using the Visual Analogue Scale (VAS). It was accepted that patients with a VAS score of 4 and higher had moderate and severe pain. These patients were started on MET and analgesic treatment, and the VAS score dropping under four was accepted as pain control. In cases where pain could not be controlled by analgesic treatment and MET, the paracetamol treatment was discontinued in • Although the number of cases is limited, preliminary results suggest that MET including tamsulosin is effective and safe in COVID-19 positive patients with distal ureteral stones. patients without any comorbid disease, and non-steroid anti-inflammatory drug (NSAID) (diclofenac potassium 50 mg once a day) treatment was started. The patients were evaluated weekly with kidney function tests, infection markers, renal dilatation follow-up with USG and KUB radiography for opaque stones. The patients were hospitalised if pain control was not achieved and complications such as acute renal failure developed. In these patients, ureterorenoscopy was performed to break the stones. The stones were pulverised using a holmium laser. When it was technically impossible to reach the stone, it was planned to insert a DJ stent alone for decompression. During the preoperative and perioperative period, it was ensured that all personnel use appropriate personal protective equipment and take all necessary measures to prevent COVID-19 transmission. In patients in whom a stent had been inserted after the endoscopic intervention, the localisation of the stent was visualised and recorded using perioperative fluoroscopy. Stonelessness was accepted as no residual stone being left in direct sight in the ureter intraoperatively. The study included 14 patients infected with COVID-19 and followed-up during the treatment process, who had presented to the Erzurum City Hospital Emergency Department between August 2020 and December 2020 with the complaint of renal colic in which distal ureteral stones were detected in the tests. The demographic, clinical characteristics of the patients, and the characteristics of the stone on presentation are summarised in All stones were unilateral. Nine (64.2%) of the stones were on the right and 5 (35.7%) were on the left. Eleven (78.6%) of the patients had not received any treatment for stone disease previously. In one patient with a hypoplastic contralateral kidney, high creatinine In total, pain control was achieved in nine patients (64.2%) with analgesic treatment and MET, and the stone was removed without invasive intervention. With this treatment, the average stone passing time was determined as 9.77 (±6.86) days. Surgical intervention was performed in a total of five patients (35.7%). These included one patient with a hypoplastic contralateral kidney, high creatinine and acute renal failure at presentation, two patients in whom pain control could not be achieved at presentation, and two patients in whom pain control was not achieved, while being followed with analgesic therapy and MET. The COVID-19 pandemic has increased the burden on the health system and hindered non-COVID-19 health services. In addition to the decrease in the bed capacity allocated to non-COVID-19 patients, professional organizations, and associations. This has led to a deviation from routine practices and the implementation of certain precautions by performing some regulations during this process. Urinary system stone disease is the third most common urinary tract disease after urinary tract infection and benign prostatic hyperplasia. 11 The majority of symptomatic stones are ureteral stones, and nearly 70% of these are distal ureteral stones. 6, 7 Acute renal colic is one of the most frequently encountered problems in the emergency department. 12 Considering this information, patients with distal ureteral stones, which are common and serious problems in urology practice, and patients infected with COVID-19, in particular, were examined in the light of the guidelines and literature on this subject under the conditions brought by the pandemic. The first radiological method to be used in renal colic is USG. EAU 2020 strongly recommends the use of NCCT to confirm the stone diagnosis after the initial evaluation. It is recommended to use KUB radiography to classify opaque and non-opaque stones and for comparison during follow-up after NCCT. 8 In our study, we also eval- The fact that our study is retrospective and that the number of patients was limited to 14 are important limitations of our study. There is a need for high-volume, prospective, randomised, and controlled studies on this subject. In most COVID-19 infected patients with renal colic and distal ureteral stone, good results can be obtained using MET. Patients with a distal ureteral stone and persistent renal colic can be safely and effectively treated by endoscopic ureteral stone treatment after taking necessary precautions. Prospective, randomized controlled studies are required on this subject. There is no conflict of interest of any authors in relation to the submission. Saban Oguz Demirdogen (writer, design, analysis), Ahmet Emre Cinislioglu (supervision, design), Nazan Cinislioglu (design), Mehmet Sefa Altay (data collection, design), Ibrahim Karabulut (data collection, design), Ozkan Polat (design), Senol Adanur (design). As authors, we declare that you can use our data. 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