Optimize the Management of Urological Tube-Related Emergencies During the Coronavirus Disease 2019 (COVID-19) Pandemic

Yang Luan; Yan Zhang; Kai Cui; Fan Li; Baolong Qin; Yajun Ruan; Kun Tang; Hongyang Jiang; Hao Li; Xiaoyi Yuan; Zhuo Liu; Xiaming Liu; Gan Yu; Shengfei Xu; Ruibao Chen; Huan Yang; Xiaolin Guo; Xiaoyong Zeng; Zhong Chen; Zhiqiang Chen; Zhiquan Hu; Xiaodong Song; Zhihua Wang; Shaogang Wang; Jihong Liu; Tao Wang

Disclosures

Transl Androl Urol. 2021;10(1):466-474. 

In This Article

Methods

Patient Population and Data collection

All emergent urological patients at Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology from January 23 (the beginning of lockdown in Wuhan) to March 23, 2020, and the corresponding period in 2019 were recruited to form this study's COVID-19 group and control group, respectively. Patients in the control group were routinely treated for urological tube-related emergencies, while patients in the COVID-19 group were managed according to the optimized principles and strategies, as described in this article.

Data including baseline characteristics (gender, age, underlying diseases, tube retention time), emergent cases number and proportion, and management outcomes (surgery time, secondary complex operation rate, two-week postoperative readmission rate, COVID-19 infection rate) for urological tube-related emergencies were compared across groups to evaluate the value of the optimized strategies.

The study was conducted in accordance with the Helsinki Declaration (as revised in 2013) and approved by institutional research committee of Tongji Hospital (IRB Approval No. 215207–100). Written informed consent was obtained from all the patients.

Optimized Principles and Strategies for the Management of Urological Tube-related Emergencies

General Principles. Evaluate the Emergent Situation in a Non-contact Way: Communicate with emergency doctors and patients to understand patients' medical histories and examination results using either voice or video call (e.g., WeChat). Evaluate the severity of each emergency by performing thorough examination. Develop preferred and alternative treatment plans before the preparation of the operating materials and entering the emergency department.

Screen for COVID-19 Before Performing Any Treatment: Conduct routine severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) nucleic acid and antibody tests before performing any necessary urological inspections. Only life-threatening situations should be considered for immediate management.

Determine the Timing of Treatment Cautiously: Regular replacement of urological tubes can be appropriately postponed until the pandemic is over as long as no obvious tube-related emergencies have occurred within the longest tube retention time. In case of tube obstruction, a patient can first try to flush the tube with sterile saline at home under the guidance of doctor by video call. For other tube-related problems, resolve current emergencies quickly and remove the etiologies when the pandemic is over.

Select Simple and Low-exposure Operations, Prioritizing Operations With High Success Rates and the Avoidance of Multiple Operations: Treatments should aim to rapidly relieve emergent conditions, provide urinary drainage, and protect renal function with minimally invasive methods. Treatments with simple steps, low accuracy requirements, short durations, and little body fluid contact are suggested to reduce potential exposure to the coronavirus. We suggest avoiding trying one method more than three times to prevent a prolonged operation. Operation methods and equipment with high success rates, rather than low cost, should be the first line of consideration. Carefully select procedures and check drainage patency postoperatively to reduce the need for multiple operations in the near future. Urological specialists with more than 5 years' work experience are best suited for performing these operations.

Perform Operations at Emergency Bedside When Possible: Perform operations in the emergency department to reduce transfers. Minimizing endoscopic and surgical procedures as far as the circumstances allow will help reduce the probability of cross-infection and excessive consumption of medical resources.

Meet Criteria for Second-level Protection: Surgeons should wear second-level protective equipment before entering the emergency department and making contact with the patients. Minimize the number of surgeons and take only the necessary instruments into the operating area. Patients should wear medical protective masks if available.

The detailed management procedures for difficult urinary catheterization (Figures 1,2), bladder clot clogging (Figure 3), dislodgment or obstruction of nephrostomy/cystostomy tube (Figure 4), dislodgment or obstruction of single-J stent (Figure 5), and sickness caused by double-J stent retention are listed in the Supplementary method section.

Figure 1.

Arrangement of urethral probe and catheter in the integration method. Insert the front end of probe (8 or 10 Fr) into the side hole of catheter lubricated with sterile paraffin oil, and then insert them together into the urethra, which possess the smooth and tough features. Dilatation and insertion can be completed in one step.

Figure 2.

Medical procedures for difficulty inserting urinary catheterization. Fully understand patients' basic condition and medical history and judge the filling degree of bladder by ultrasonography. Anaesthetize and lubricate urethral mucosa before careful insertion of silica gel catheter with suitable size. If fail, urethra dilatation, probe and catheter integrative insertion, or suprapubic cystostomy can be chosen step by step.

Figure 3.

Medical procedures for bladder blood clots clogging. Judge the bleeding severity and source of blood clot by medical history, blood test and urinary imaging examination. Insert/replace a three-way urinary catheter and choose to suck and wash or endoscope assisted operation according to the severity of bleeding and obstruction.

Figure 4.

Medical procedures for dislodgment or obstruction of nephrostomy/cystostomy tube. Detect hydronephrosis, urine retention and the position of nephrostomy/cystostomy tube by medical history and imaging examination. Then, Identify the dislodgment or obstruction of nephrostomy/cystostomy tube. Insert a same or small size tube when nephrostomy/cystostomy tube is dislodged. If failed, try sinus tract dilatation with the guidance of a stiff guidewire or puncture again. Replace and flush nephrostomy/cystostomy tube when obstruction occur.

Figure 5.

Medical procedures for dislodgment or obstruction of single-J stent. Detect hydronephrosis and the position of single-J stent by medical history and imaging examination. Then, identify dislodgment or obstruction of single-J stent. Slight dislodgment can be re-inserted, while obvious/complete dislodgment or obstruction should replace a new single-J stent. If fail to insert a guidewire to pelvis, try to fix a bilateral open-ended ureteral catheter and detect the ureteral lumen with a hydrophilic guidewire. If all methods above do not work, percutaneous nephrostomy is suggested.

Statistical Analysis

The case numbers (constituent ratio) across the two groups were statistically analyzed and compared using a two-tailed chi-square test. The age and time indices were presented as the mean ± standard deviation (SD) and analyzed using the Student's t-test in Prism 6. A two-sided P value <0.05 was considered statistically significant.

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