Covid-19: A Double Edged Sword-Rise in Complicated Ureteric Stone Disease

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Introduction
The Coronavirus 2019 (COVID-19) pandemic has become a global threat and a major source of human health concern in 2020 [1]. It also poses a huge challenge to healthcare infrastructure worldwide with a huge unprecedented impact been suffered by surgical specialities [2]. Every procedure had to be meticulously triaged depending upon the urgency. Due to the disruption of the smooth work environment, shortage of workforce and hospital supplies, patients were initially encouraged to minimize hospital contact, unless deemed urgent; as well as the fear among patients of contracting covid has led them collectively to prolong and ignore health concerns.
Renal and ureteric colic is one of the very common presentations in daily surgical and urological clinics [3]. Ureteric colic occurs as a result of obstruction of the urinary tract by calculi at the narrowest anatomical areas of the ureter: the Pelvi-Ureteric Junction (PUJ), near the pelvic brim at the crossing of the iliac vessels, and the narrowest We hypothesize that this delay in treatment would increase the rate of complicated ureteric calculus. We performed a retrospective study to analyse comprehensively the effect of COVID-19 upon ureteric calculus in 2020 when compared to last year.

Methods
After obtaining ethical committee clearance from our hospital; we retrospectively analyzed all those patients who were admitted to the Department of Urology, SCB Medical College and hospital, Cuttack between 1 st March to 30 th September, 2020 and a similar time period in 2019.

Selection of the Population
The priority of disease was classified according to the European Association of Urology (EAU) Guidelines Office Rapid Reaction Group (low priority, intermediate priority, high priority, and emergency) [8]. Low and intermediate were categorized as a non-complicated ureteral stone disease while high and emergency as complicated ureteral stones.
A total of 2 groups were selected: The complicated ureteral stone disease (CUSD) patients those who got admitted to the hospital for treatment during pandemic i.e., between 1 st March to 30 th September 2020.
The complicated Ureteral Stone Disease (CUSD) patients who came to the hospital during the same duration for treatment in 2019.
In particular, data was collected ( Table 1) incorporating age of the admitted patients, symptoms upon admission, Total leucocyte count, serum urea/creatinine, characteristics of ureteral stones (number, location, size), and degree of hydronephrosis.
Treatment received by the patient-emergency divergent procedures like DJ stent, percutaneous nephrostomy or definite treatment such as endoscopic stone surgeries.
Patients in 2020 were also telephonically enquired (Table 2) whether they felt that pandemic led to any delay in getting treatment, the reasons for their delay, whether they tried or were forced (because of COVID-19 restrictions or individual fear) to look for locally available non-expert doctors or health workers before visiting our hospital.

Statistical analysis
Statistical analysis was conducted to evaluate the null-hypothesis that "there is no change in the rates of complicated ureteral stone during the COVID-19 pandemic restriction period. " Unpaired Student's t-test will be used to compare continuous variables. The categorical data will be assessed using chi-square test.

Results
On examining the data acquired, it was found that the mean age of pre and post covid periods didn't have any significant difference. Stone characteristics such as the size of the ureteric calculus, location of the calculus also remained indifferent. Although analysis of the serum creatinine and total leucocyte count on admission was statistically higher in COVID-19 group (p=0.028 and 0.014 respectively). The degree of hydronephrosis was found to be statistically insignificant, but a greater percentage of COVID-19 period patients presented with higher grades of hydronephrosis.
Patients' admission was categorized according to EAU priority classification [8]. We found that there was a statistically significant proportion of patients admitted in COVID-19 period classified into high and emergency priority groups when compared to last year's noncovid group (p=0.025).
It was observed that patients in COVID-19 group were more conservatively treated (p=0.005) with a higher percentage of patients being managed with DJ stent and percutaneous nephrostomy while in the non-covid group they were planned with more definitive procedures as per disease per sec. Also greater number of patients were attempted to be treated with medical expulsion therapy in the COVID-19 group (p=0.001) even for stones more than 6mm in size.  Another observation was that higher percentage of patients had already taken antibiotics on admission (p=0.005) during COVID-19 before visiting our hospital. Patients from the rural areas due to covid restrictions attempted more locally available resources consulting local health workers and alternative medicine practitioners in a greater percentage. Although very few patients had access to it, telemedicine proved a big help in rural areas to avail proper advice from expert doctors.
Patients in the COVID-19 group responded to questionnaires that approximately 82% felt their treatment got delayed because of government protocol of lockdown and travel restrictions (46%), many avoided going to the hospital especially those who had fever out of fear that they may get diagnosed with COVID-19 and will be kept in quarantine centers and others out of fear of catching COVID-19 at the hospital from other patients.

Discussion
Renal and ureteral stone diseases are quite prevalent in our society. Many of the ureteric calculus are diagnosed post ureteric colic pain episode. Few calculi which are non-obstructing presents with various symptoms such as fever, flank pain or lower abdominal pain, strangury, urinary complaints, or hematuria. Sometimes they become a life-threatening issue when they present with sepsis or acute kidney injury and decompression becomes a life-saving procedure in such circumstances [6].
Given the pandemic there was consensus that benign urological surgeries must be deferred considering that hypertension, chronic kidney disease may increase the risk of COVID-19 related serious events [9][10][11][12]. In our study, we demonstrated how the COVID-19 pandemic had an impact upon patients with ureteric calculus. There was an increase in complicated ureteric calculus owing to a delay in proper treatment.
Although stone characteristics were quite similar in both the covid and non-covid groups, former group presented with a higher percentage of patients with grade 2/3 hydronephrosis, probably due to delayed presentation. Gul M, et al. [13] performed a similar study where they had derived similar conclusions of increase in the complicated ureteric stones and increase in serum creatinine and leucocyte counts in the covid group. Flammia, et al. [14] performed a similar study and found out that serum creatinine and leucocyte count was higher in the covid group, degree of hydronephrosis wasn't significantly increased, but on the contrary, to our study, they didn't find any significant increase in the complicated ureteric stone disease when compared to last year. Also, they concluded that the plan of management in both the groups was unchanged in COVID-19 times while our study showed that patients, in general, were more conservatively treated with decompression procedures than definitive treatment on the first admission.
Patients didn't have resources and were more reluctant to visit hospitals. Government protocol during the pandemic in the form of lockdown, travel restrictions, and patients fearing of contracting covid, all corroborated into the delay in getting treatment. Patients in rural areas primarily were more dependent upon locally available resources such as village health care workers, alternative medicine practitioners, and many with a history of similar complaints in the past attempted at self-prescription of drugs based of earlier treatments.
Owing to all this delay in consultation there was a significant increase in the complications due to ureteric calculus. Also because of the pandemic protocol in place in hospitals patients were treated more conservatively with diversion procedures rather than definitive procedures to decrease the number of admissions/number of days of admission and also to reduce the risk for transmission of the pandemic from patients to the medical staff.
Telemedicine although is still in preliminary stages in our country but can prove to be very helpful for distant patients with no specialist in their areas and needs to be made available to an increasing number of patients.

Conclusions
As every surgical specialty was deeply affected by the pandemic, surgeons should try to inculcate various guidelines to continue to provide vital due care to the non-covid patients safely and effectively manner. We must balance the risks and benefits of any perceived delay in treatment, with the costs of utilizing limited personal protective equipment (PPE) and potential exposure of health care workers and/ or patients to the deadly virus.
Flammia, et al. [15] formulated a framework to provide a structure for case-by-case consideration to prioritise kidney stones during COVID-19. Similarly, other guidelines balancing the risk of COVID-19 spread vs complications due to treatment delay need to be introduced.
Learning from the recent pandemic of COVID-19 and understanding that such situations can present anytime in near future too, we need to evolve our guidelines in a manner that non-covid uncomplicated cases get proper treatment in due time rather than turning them into complications. Telemedicine needs to be made more available in distant areas which have no specialist facilities nearby.

Conflicts of Interest
There are no conflicts of interest.