This document discusses recommendations for endourological stone management during the COVID-19 pandemic. It suggests minimizing elective surgeries to preserve resources for COVID-19 patients. For stone patients requiring surgery, it proposes carefully selecting those at highest risk of complications. It also recommends conservative management when possible to reduce hospital visits and utilizing telemedicine. The aim is to minimize virus spread while preventing severe stone complications from overwhelming healthcare systems.

1. European Urology
Endourological Stone Management in the Era of the COVID-19
--Manuscript Draft--
Manuscript Number: EURUROL-D-20-00386R1
Article Type: Editorial
Keywords: COVID-19, outbreak, coronavirus, urology, endourology, stone
Corresponding Author: Silvia Proietti
San Raffaele Hospital, Ville Turro Division
Milan, ITALY
First Author: Silvia Proietti
Order of Authors: Silvia Proietti
Franco Gaboardi
Guido Giusti
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Title ENDOUROLOGICAL STONE MANAGEMENT IN THE ERA OF THE
INVISIBLE ENEMY COVID-19
First Name Proietti Silvia
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Giusti G: consultant for Coloplast, Rocamed, Olympus, Boston Scientific, BD-Bard, Cook
Medical, Quanta system
Proietti S: consultant for Quanta System
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6. Endourological Stone Management in the Era of the COVID-19
S. Proietti, F. Gaboardi, G. Giusti
The COVID-19 pandemicoutbreak is disrupting health care systems worldwide. In this difficult
situation, all hospitals are asked to temporarily suspend elective surgery, especially for benign
pathologies.
Herein we provide some proposals for the management of stone patients during the COVID-19
pandemicoutbreak to, minimizeing virus dissemination and cross- infection and, withouthe
impacting on the already overburdened health systems.
Take Home Message

7. Endourological Stone Management in the Era of the Invisible Enemy COVID-19
Silvia Proietti *S.1, Franco Gaboardi F1, Guido Giusti G.1
1-European Training Center ofor Endourology, Department of Urology, IRCCS San Raffaele
Hospital, Ville Turro Division, Milan, Italy
*Corresponding author.: Silvia Proietti, Department of Urology, San Raffaele Hospital, Ville
Turro Division, Via Stamira d’' Ancona 20, Milan, Italy.
E-mail address:; proiettisil@gmail.com (S. Proietti).
The corona virus disease 2019 (COVID-19) pandemicoutbreak is disrupting non-COVID-19
health care services and jeopardizing the ability of the medical systems to respond to routine
patient needs.
In hospitals within the geographic COVID-19 hotspots zones, the surgical departments have
been asked to minimize or temporarily suspend elective scheduled elective operations to
addressface the overwhelming and devastating increase inof COVID-19 patient care needs.
The dDe-escalation of surgical activity should depend on the emergency status of individual
health care systems and what each hospital requires ofrom the urological departments.
The aim of this strategy aims to free uprecruit more inpatient beds, anesthesiologyist staff,
health care personnel, personal protective equipment (PPE), terminal cleaning supplies, and
operating rooms (ORs) that may become intensive care units (ICUs).
Moreover, athe reduction inof elective surgery lowers the need forrisk of ICUhaving
postoperative care of critical patients within ICU, leaving space forto COVID-19 patients
requiring ventilators.
This strategy helps also to addressflatten the COVID-19 curisis byve, reducing the rate of
new cases that are active at any given time, which translates into increasinged health system
availability to prepare and respond to the epidemic, without becoming overwhelmed.
The unfortunate circumstance of being one of the first endourology tertiary referral centers of
Endourology involved in the COVID-19 Italian epidemic, promptedled us to provide some
proposals for the management of stone patients during the COVID-19 outbreak, minimizing
virus dissemination and cross 0 infection, without impacting on the already overburdened
health system.
First of all, it is important to reduce the number of hospitalized patients and screen all of
them before admission to the department. A detailed flow-chart for patient screening may be
helpful as a guide during the COVID-19 pandemicoutbreak (Fig.ure 1).
Any patient fulfilling any of criteria for confirmed or suspected COVID-19 and requiring
urgent endourological surgery, should be managed in a dedicated OR with.
This is characterized by a negative pressure environment and a separate access from the other
ORs; the same anesthesia machine must only be used for COVID-19 cases [1].
For those hospitals in whichwhere a dedicated OR is not available, all protocols of
postoperative cleaning protocols should adhere to institutional central disease control
instructions.
Access to the OR should be strictly limited to surgeons, anesthetists, and the nursinge team.
AllEvery training activity in the center should be suspended.
Nonetheless, Hhealth workers must stillhave to follow occupational health and safety
procedures according tofollowing the protocols provided by each hospital.
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Manuscript

8. During the COVID-19 pandemicoutbreak, a shortage of health care personnel should be
anticipated because of; this is attributable to spiking demand, COVID-19 illness among
health workers COVID-19 illness, and a high rate of absenteeism rate. During crises,
absenteeism among health care staff can reach up to 30% [2].
It is also of the utmost importance to stop all elective outpatient clinics in order to avoid any
gatherings of people within the hospital; only emergency consultations should be carried out.
Wherever possible, one temporary solution to replace outpatient appointments could be
viathrough teleconsultations [3].
Patients with renal colic should be managed conservatively as much as possible to avoid
admission to anthe overwhelmed emergency department.
Stone patients scheduled for surgery should be thoughtfully selected according to the surgical
priority (Fig.ure 2).
Even though urinary stone disease represents a benign condition, it can lead in a non-
negligible number of cases it can lead to potential severe septic complications that could
increase the burden on emergency services [4].
Over recent decades, elective and emergency admissions related to urolithiasis have been
increasing [5]. and Uurosepsis due toas result of an untreated obstructed infected kidney or a
calculi matrix acting as a reservoir for bacterial growth, is more frequent than in the past [4].
It is noteworthy that even with the decompression of the urinary system, antibiotic therapy,
and other supportive measures, 15% of these patients require ICU admissions, with thea
mortality rate as high as 8–-10% [4].
In the case of an obstructed/infected kidney, only the decompression of the system is
suggested, which; this can be achieved safely viaby eitherboth stenting or percutaneous
nephrostomy [6]. In theis current panepidemic scenario, it is advisable to take extra effort to
avoid the latter because offor the high risk of inadvertent removal and likely long delay tof
subsequentthe following surgical lithotripsy. Whenever possible, the ureteral stent orand
nephrostomy tube should be placed under local anesthesia, sparing a ventilator [7].
According to these data, it is meaningful to cCarefully reviewselect of the waiting list for the
stone patients by can
reviewing the waiting list in order to identify thosepatients at low risk for whom a
procedurethat can be postponed. Once identified, it is advisable that the surgeon should
personally inform these patients that this was a medical decision based on the patients’
history and ongoing medical emergenciesy and not an administrative one.
Another concern is how to manage the patients who already hadbearing a ureteral stent for
complicated urolithiasis before the COVID-19 pandemicoutbreak. In some cases, infection
associated with urinary stents can lead to significant morbidity such as acute pyelonephritis,
bacteremia, urosepsis, and even death [8]. ThereforeAs such, this subset of patients should be
considered with some priority in order to avoid an extended delay. Of course, tThe stent
indwelling time should be a factor to be considereded in the prioritizationy list process,
keeping in mind that the majority of ureteral stents can be left in place for up to 6–-12
months.
At present, even though the evidence is insufficient to support antibiotic prophylaxis forin
this scenario of patients with indwelling stents, given the likely delays in surgery, at least
some pulse antibiotic therapy could be consideredtemplated to reduce the risk of urosepsis
and consequent requirementshortage ofor a mechanical ventilator [9].
Depending on the de-escalation phase, outpatient procedures should be pursued and stenting
with strings should be considered after uneventful procedures to avoid a clinic visit for stent
removal.
Moreover, endourologists have to be prepared to subsequently manage more difficult cases
forin those patients whose procedure have been postponed because of lower surgical priority;

9. in addition, a significant increase in the waiting lists should be anticipated. Nevertheless,
these patients should be followed routinely viaby telephone calls to monitor their “stone
status”.
Standard sterilization of the endourological reusable armamentarium is also considered safe
also in terms of COVID-19 cross-contamination because so far the virus has not been
detected in the urine, although the evidence is not yet robust [10].
In conclusion, inspired by the Roman aphorism “Si vis pacem, para bellum” (if you want
peace, prepare for war), endourologists have to be prepared to fight the COVID-19
pandemicoutbreak, to returncover to a long-lasting normality as soon as possible.
Conflicts of interests: Guido
Giusti is aG: consultant for Coloplast, Rocamed, Olympus, Boston Scientific, BD-Bard,
Cook Medical, and Quanta Ssystem.
Silvia Proietti is aS: consultant for Quanta System. Franco
Gaboardi has nothing to discloseF: none.
References
1 Ti LK, Ang LS, Foong TW, Ng BSW. What we do when a COVID-19 patient needs an
operation: operating room preparation and guidance. Can J Anesth. In press. 2020;
https:/doi.org/10.1007/s12630-020-01617-4. [Epub ahead of print]
2 Damery S, Wilson S, Draper H, et al. Will the NHS continue to function in an influenza
pandemic? A survey of healthcare workers in the West Midlands, UK. BMC Public
Health 2009; 9:142
3 Hollander JE, Carr BG. Virtually perfect? Telemedicine for COVID-19. N Engl J Med.
In press. 2020 https://DOI: doi.org/10.1056/NEJMp2003539 [Epub ahead of print]
4 Fukushima H, Kobayashi M, Kawano K, Morimoto S. Performance of Quick Sequential
(Sepsis Related) and Sequential (Sepsis Related) Organ Failure Assessment to predict
mortality in patients with acute pyelonephritis associated with upper urinary tract calculi.
J Urol 2018; 199:1526-15–33.
5 Rukin NJ, Siddiqui ZA, Chedgy ECP, Somani BK. Trends in upper tract stone disease in
England: evidence from the Hospital Episodes Statistics database. Urol Int. 2017;
98:391–-396.
6 The European Association of Urology. (EAU) uUrolithiasis gGuidelines 2019.
https://uroweb.org/guideline/urolithiasis/
7 Stensland KD, Morgan TM, Moinzadeh A, et al. Considerations in the triage of urologic
surgeries during the COVID-19 pandemic. Eur Urol 2020. In press[Epub ahead of print].
8 Paick SH, Park HK, Oh SJ, Kim HH. Characteristics of bacterial colonization and
urinary tract infection after indwelling of double-J ureteral stent. Urology 2003; 62:214-–
7.
9 Tenke, P., Kovacs, B., Benko, Rr., Ashaber, D,. & Nagy, Ee. Continuous versus
intermittent levofloxacin treatment in complicated urinary tract infections caused by
urinary obstruction temporarily relieved by foreign body insertion. Int. J. Antimicrob.
Agents 2006; 28: S82–-85.
10 Wang W, Xu Yy, Gao Rr, et alLu r, Han k, Wu G, Tan W. Detection of SARS-CoV-2 in
different types of clinical specimens. JAMA. In press. 2020; https://doi.org/DOI:
10.1001/jama.2020.3786 [Epub ahead of print]
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Commented [MN1]: For AQF. Refs 1 and 2. If available,
please update publication details.
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Commented [MN2]: For AQF. Ref 7. Please add doi or
publication details, if available.
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publication details.
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Commented [MN4]: For AQF. Ref 10. If available, please
update publication details.
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10. Fig.ure 1 –: Flowchart for triage of urological triage patients duringflow-chart in the
COVID-19 pandemicoutbreak.
ER = emergency room; OR = operating room; PPE = personal protective equipment.
Fig.ure 2 –: Prioritization schemey line forin stone patients scheduled for surgery
during thein COVID-19 pandemicoutbreak.
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11. Illustration Click here to access/download;Illustration;Figure 1 .jpg

12. Illustration Click here to access/download;Illustration;Figure 2 .jpg

13. Dear Editor,
Thanks for your outstanding suggestions.
We have modified the manuscript accordingly.
Thanks.
Best regards,
Silvia Proietti
Revision notes