key: cord-0911401-1zuzi3uh
authors: Kachroo, Naveen; Wright, Henry C.; Sivalingam, Sri
title: A Tale of Two Eras: The Effect of the COVID-19 Pandemic on Stone Disease Presentations
date: 2020-07-06
journal: Urology
DOI: 10.1016/j.urology.2020.06.042
sha: 70c5c2394a60ed2c35b42577786c25cf198fe495
doc_id: 911401
cord_uid: 1zuzi3uh

nan

The novel coronavirus disease 19 (COVID) pandemic triggered a national emergency declaration in the United States (US) on March 13 th 2020. The resultant diversion of healthcare and public attention towards disease exposure avoidance, propagated a concerning reduction in Emergency Department (ED) presentations for many serious medical conditions 1 . Urinary stone disease (USD) is a frequent cause of ED visits and can be life or organ threatening if not treated in a timely manner 2 . One small Italian study showed that the pandemic had no effect on USD emergency presentation rates 3 but its effect in a larger US cohort remains unknown. During the COVID-era, there was a 36% reduction in emergent USD presentations compared to an equivalent Pre-COVID era. Interestingly, there was no difference in baseline characteristics or clinical severity at presentation (measured by systemic inflammatory response syndrome criteria, serum creatinine, urinary tract infection or need for emergent intervention) ( Table 1) . However, a higher proportion of COVID-era patients did have evidence of acute kidney injury (AKI) based on RIFLE classification 4 (4.7% vs 2.6%) potentially suggestive of a delay in presentation.

The COVID-era resulted in a measurable shift in subsequent patient management. There were significant delays having a Urology clinic visit (mean 15 days versus 7 days Pre-COVID, p<0.0001) and a seismic shift towards these being virtual or telephone visits (from 0% to 94%) despite availability of this technology during both periods. Given most stone cases require prompt management to avoid a sequelae of complications, this delay did not affect the time to receive definitive management which is in part due to the structured Cleveland Clinic Operative Tier system created to stratify urology cases based on emergent need during the pandemic 5 . For those undergoing ureteroscopy or percutaneous nephrolithotomy, where post-procedure ureteral stent placement is common, we found a considerable practice shift towards not leaving stents (12 to 66%) and also more stents left with a string (7% to 16%), both removing a further patient encounter for stent removal, in addition to eliminating potential COVID exposure risk. Of note, none of these patients had a subsequent ED visit or resultant complication suggestive of this being a suitable future management change consideration for appropriate patients.

To our knowledge, this represents the first US based analysis of the effect of the pandemic on USD presentations and highlighted a measurable reduction in ED presentations with higher rates of AKI and also interesting changes in Urology practice management patterns. With the pandemic still raging on with no clear end in sight, the true impact this will have on our stone clinical practice remains to be fully determined. 

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