Urology Journal

Objectives: To review the current literature on the presence of COVID-19 virus in the urine of infected patients
and to explore the clinical features that can predict the presence of COVID-19 in urine.
Materials and Methods: A systematic review of published literature between 30th December 2019 and 21st June
2020 was conducted on Pubmed, Google Scholar, Ovid, Scopus, and ISI web of science. Studies investigating
urinary viral shedding of COVID-19 in infected patients were included. Two reviewers selected relative studies
and performed quality assessment of individual studies. Meta-analysis was performed on the pooled case reports
and cohort with a sample size of ≥ 9.
Results: Thirty-nine studies were finally included in the systematic review; 12 case reports, 26 case series, and
one cohort study. Urinary samples from 533 patients were investigated. Fourteen studies reported the presence
of COVID-19 in the urinary samples from 24 patients. The crude overall rate of COVID-19 detection in urinary
samples was 4.5%. Considering case series and cohorts with a sample size of ≥ 9, the estimated viral shedding
frequency was 1.18 % (CI 95%: 0.14 – 2.87) in the meta-analysis. Urinary viral load in most reports were lower
than rectal or oropharyngeal samples. In adult patients, urinary shedding of COVID-19 was commonly detected
in patients with moderate to severe disease (16 adult patients with moderate or severe disease versus two adult
patients with mild disease). In children, urinary viral shedding of COVID-19 was reported in 4 children who all
suffered from mild disease. Urinary viral shedding of COVID-19 was detected from day 1 to day 52 after disease
onset. The pathogenicity of virus isolated from urine has been demonstrated in cell culture media in one study
while another study failed to reveal replication of isolated viral RNA in cell cultures. Urinary symptoms were not
attributed to urinary viral shedding.
Conclusion: While COVID-19 is rarely detected in urine of infected individuals, infection transmission through
urine still remains possible. In adult patients, infected urine is more likely in the presence of moderate or severe
disease. Therefore, caution should be exerted when dealing with COVID-19 infected patients during medical interventions
like endoscopy and urethral catheterization especially in symptomatic adult patients while in children
caution should be exerted regardless of symptoms.

Purpose: The safety and feasibility of percutaneous nephrolithotomy (PCNL) compared with retrograde intrarenal surgery (RIRS) are debated. This systematic evaluation was performed to obtain comprehensive evidence with regard to the treatment outcomes of PCNL compared with RIRS for management of renal stones in patients with solitary kidney.

Material and Methods: A systematic search of Medline, Embase, Pubmed, Web of Science, CNKI, Scopus and the Cochrane Library was performed to identify studies that compared PCNL with RIRS for management of renal stones in patients with solitary kidney and published up to Aug 2019. Outcomes of interest included perioperative variables, complications, and stone-free rate (SFR).

Results: Four studies assessing PCNL vs. RIRS for renal stones larger than 2cm were included for meta-analysis. Although patients underwent PCNL have higher initial SFR than RIRS (OR: 3.72, 95% CI:2.38 to 5.83; P＜0.001), patients underwent RIRS have less intraoperative blood loss (dropped Hb: WMD= 3.49 g/L, 95% CI:2.83 to 4.15; P＜0.001), lower blood transfusion rates (OR= 5.31, 95% CI:1.36 to 20.68; P=0.02), and higher incidence rate of steinstrasse (OR:0.20, 95% CI:0.04 to 0.91; P=0.04). All the other calculated results including operation time (WMD: -9.87 minute, 95% CI:-30.11 to 10.37; P=0.34), final SFR (OR:1.65, 95% CI:0.80 to 3.42;P=0.18) and overall complications (OR:1.22, 95% CI:0.78 to 1.93; P=0.38) are similar between the two groups.

Conclusion: Our results indicate that PCNL has higher initial SFR than RIRS in the treatment of renal stones larger than 2cm in patients with a solitary kidney, the overall complications were similar in both groups. However, RIRS, with less blood loss and transfusion rate, may be an alternative in selected patients. But we need to pay more attention to the incidence rate of steinstrasse after RIRS.

Purpose: Alpha-blockers have been proven as an effective method for increasing the stone expulsion rate of distal ureteral stones. Limited studies have focused on doxazosin; its efficacy remained unclear. We performed this meta-analysis to investigate the efficacy and safety of doxazosin for patients diagnosed with distal ureteral stones less than 10mm.

Materials and Methods: We systematically searched Ovid MEDLINE®, Cochrane Library, EMBASE, and PubMed for articles comparing doxazosin and conventional care or tamsulosin for distal ureteral stones through October 2019. The outcome measures were stone expulsive rate (SER), stone expulsive time (SET), pain episodes, analgesics consumption, and adverse events.

Results: We included 12 studies involving 836 participants with distal ureteral stones less than 10mm in our review. The present meta-analysis showed doxazosin could significantly increase SER [RR=1.64,95%CI (1.32, 2.04), P  < 0.00001], shorten SET [WMD=-3.97,95% CI (-5.68, -2.27), P  < 0.00001] compared with conventional care. In the subgroup analyses, doxazosin showed no benefit in the children subgroup (<16 years old) [RR=1.63,95% CI (0.73,3.64), P  =0.23]. No statistically significant difference was observed regarding the effectiveness of doxazosin and tamsulosin in SER, SET, and safety. 9 in 286 participants reported doxazosin-related adverse events; most were mild to moderate.

Conclusion: This meta-analysis may suggest that doxazosin is a safe and effective MET for distal ureteral stones less than 10mm. It is not demonstrated to have any significant difference with tamsulosin in SER, SET, and safety. However, it showed no benefits for patients<16 years old.

Purpose: To review the safety and effectiveness of tubeless percutaneous nephrolithotomy (PCNL) with an externalized ureteral catheter (EUC) compared with standard PCNL with nephrostomy tube and tubeless PCNL with double-J (DJ) stent following uncomplicated PCNL and the absence of residual stones.

Materials and Methods: Patients with kidney stones who underwent uncomplicated PCNL between January 2000 to December 2017 and had no residual stones were retrospectively evaluated. The 766 patients were divided into standard PCNL with nephrostomy tube (group 1; 350 patients), tubeless PCNL with DJ stent (group 2; 189 patients), and tubeless PCNL with EUC (group 3; 227 patients). Demographic characteristics, stone-related factors, perioperative and postoperative parameters were analyzed.

Results: Demographic and stone-related characteristics were comparable. The differences in the mean operative time and complication rates were not significant. Postoperative hospitalization period was shorter in group 3 (3.19 ± 2.2 days) compared with group 1 (4.12 ± 2.4 days; p < .001) but not to that of group 2 (3.44 ± 2.8 days; p = .680). Postoperative pain score was lower in group 3 (3.24 ± 1.1) compared with both group 1 (6.36 ± 1.7; p < .001) and group 2 (4.85 ± 1.1; p < .001). Urine leakage complication was lower in group 3 (0.4%) compared with group 1 (2.9%, p = .038) but not to that of group 2 (0.5%; p = .897).

Conclusions: Tubeless PCNL is effective and safe for uncomplicated PCNL in the absence of residual stones. Tubeless PCNL with EUC is associated with decreased pain, hospitalization time, and urine leakage compared with standard PCNL. However, it is only associated with decreased pain when compared with tubeless PCNL with DJ stent.

Purpose: To assess the cost-effectiveness of medical expulsive therapy (MET) versus observation for large distal ureteral stones in China and provide preliminary evidence for the determination of the course of MET by mathematical estimation.

Materials and Methods: With linear success rate assumptions, a decision tree was constructed by TreeAge Pro 2011 software. The stones passage rates after observation or receiving 0.4 mg daily tamsulosin were estimated according to a large randomized clinical trial (RCT). The costs of ureteroscopy, drugs and examinations were estimated according to related price from pharmacies or hospitals, or the guidance price published by the government. MET was also compared with observation by the sensitivity analysis. The effectiveness of MET or observation was presented by quality-adjusted life-day. Mathematical estimation of stone expulsion time was made by using a decision-analytic Markov model under the assumption that the daily stone expulsion probability is constant.

Results: In China, the MET was associated with a $295.1 cost advantage over observation. The cost of ureteroscopy has to decrease to $77.8 to reach cost equivalence between observation and MET. Observation is cost-effective only if ureteroscopy is very cheap or the difference of stone expulsion rates is insignificant. The estimated expulsion time was much longer than those reported in above mentioned RCT.

Conclusion: Due to the high cost of ureteroscopy, MET showed a cost advantage over observation in treating distal ureteral stones in China. The daily stone passage rate was inconstant. More studies are needed to find the appropriate duration of MET.

Purpose: To explore the clinical efficacy of ureteroscopic occluder and stone retrieval basket combined with holmium laser in the treatment of upper ureteral calculi.

Materials and Methods: This retrospective study included 103 patients treated with ureteroscopic holmium laser lithotripsy for upper ureteral stones. Patients were divided into two groups based on the device applied during lithotripsy: group 1 for the occluders (52 cases), and group 2 for the stone retrieval baskets (51 cases). The stone upward migration rate, stone-free rate, and complication rate during or after surgery were compared.

Results: The operation time was 45 ± 7 min in the occluder group and 43 ± 5 min in the basket group (P = .111). There was no significant difference between the stone retropulsion rate (13% vs. 16%, P = .787). The successful one-time stone-free rate was 92% vs. 94% (P = .999) respectively. Furthermore, there was no significant difference in the hospitalization time (P = .581) and postoperative complication rate (P = .715) between 2 groups.

Conclusion: The treatment of upper ureteral calculi with ureteroscopic occluder and stone retrieval basket combined with holmium laser lithotripsy can both effectively prevent intraoperative stone retropulsion, improve the success rate of one-time lithotrips. The occluder was more cost-effective than the stone retrieval basket, yet it was a more desired choice for over dilated ureters.

Purpose: To investigate the safety and efficacy of Minimally Invasive Percutaneous Nephrolithotomy (MPCNL) combined with Vacuum-assisted Access Sheath in the treatment of obstructive calculous pyonephrosis.

Materials and Methods: Seventy-six patients with obstructive calculous pyonephrosis, who were planned to receive MPCNL, were randomly divided into two groups. Group A was treated with Amplatz sheath combined with Cyberwand double probe ultrasound lithotripsy, and group B was treated with Vacuum-assisted Access Sheath (VAAS, ClearPetra, Well lead Medical) combined with holmium laser lithotripsy. The primary outcome was the operation successful rate. Other perioperative, and postoperative data such as operation time, stone free rate and complications were compared between groups.

Results: Single 20F access sheath was established in all cases. All patients underwent one-stage procedure. Compared with group A, group B had a higher initial stone-free rate (84.2% vs 63.1%, P= .037). The operation time of group B was 56.3 ± 19.83 min, significantly shorter than that of group A at 70.4 ± 14.83 min. The complication rate of B group was 15.8%, which was lower than that of group A (P= .035 ). Five patients (15.8 %) of group B had a postoperative fever (>38.5 ºC) (Clavien grade 2) that required additional antibiotics; whereas 8 patients (21.1 %) of group A (P= .361). There was no blood transfusion in group A, and one case in group B required transfusion.

Conclusion: One-stage MPCNL combined with Vacuum-assisted Access Sheath and holmium laser lithotripsy is a simple, safe, effective, and ergonomically practical method for selected patients with obstructive calculous pyonephrosis.

Purpose: Several studies have compared the short-term outcomes of extraperitoneal robot-assisted laparoscopic radical prostatectomy (EP-RALP) and transperitoneal RALP (TP-RALP). The study was designed to evaluate the long-term outcomes of the two methods.

Materials and Methods: A prospective, non-randomized study was conceived. The demographics and operative outcomes of patients with prostate cancer undergoing RALP from September 2016 to January 2017 at our center were included.

Results: A total of eighty-six patients were enrolled. Thirty-seven patients underwent EP-RALP, and forty-nine patients received TP-RALP. No significant difference was observed in age, body mass index, pathological T stage, pathological N stage, M stage, 2014 International Society of Urological Pathology group, comorbidities or American Society of Anesthesiologists score. A lower preoperative prostate-specific antigen (PSA) was detected in the EP-RALP group. No significant differences were observed in overall operation time, robotic console time, surgical margin status, postoperative hospitalization time, drop of hemoglobin and complications, except that patients with EP-RALP had a shorter time to first exsufflation after surgery than those with TP-RALP (41.35 vs. 51.80 h, P < .001). Postoperative PSA until 12 months was deemed comparable in both groups. Complete continence until 12 months after surgery was desirable but not significantly different between two groups (75.0% in EP- RALP vs. 86.7%. in TP-RALP, P = .179).

Conclusion: The long-term outcomes of EP-RALP were analogous to those of TP-RALP. Therefore, EP-RALP is an alternative approach for patients with localized prostate cancer.

Keywords: prostate cancer; robot-assisted prostatectomy; extraperitoneal approach; transperitoneal approach; enhanced recovery after surgery

Objective: To determine disease-related predictors for the occurrence of prostate specific antigen (PSA) failure in Iranian prostate cancer patients who underwent radical prostatectomy.

Methods: In this cohort study, we enrolled eligible patients with prostate cancer who underwent radical prostatectomy at our center between 2001 and 2018. The primary endpoint was the incidence of postoperative biochemical failure, defined as two consecutive PSA levels >= 0.2 ng/dl. Patients with TNM stage >= III, Gleason score >=8, or baseline PSA above our calculated cut-off level were considered as high risk. Kaplan–Meier survival method and Cox proportional hazards regression analysis were used for determining the biochemical relapse-free survival and its predictors.

Results: Data of 959 patients (age=61.2 ± 6.4 years) were analyzed with a median follow up of 36 months (range 6 months to 18 years). A total of 97 patients (10.1%) developed biochemical failure at the time of analysis who had a significantly older age and longer follow-up duration (P=0.024 and P<0.001, respectively). Preoperative PSA level of 8.85 mg/dl could predict the occurrence biochemical failure with a sensitivity of 83.2% and specificity of 39.2% (Area under the curve=0.601, 95% CI: 0.541-0.662; P=0.001). In the multivariate analysis, higher preoperative PSA, Gleason score?8, and high-risk TNM stage were independent predictors for biochemical relapse (P=0.029, P=0.001, and P=0.008, respectively).

Conclusion: Preoperative PSA, Gleason score, and TNM stage were independent predictors for biochemical failure following radical prostatectomy in prostate cancer patients. We also determined a lower cut-point for PSA that could predict biochemical failure.

Purpose: Role of pulmonary metastasectomy of renal cell carcinoma (RCC) is significant considering its contribution to survival rates. The aim of this study is to present the prognostic factors affecting the surgical outcomes and long-term survival.

Materials and Methods: Forty-eight patients who had undergone pulmonary metastasectomy of RCC between 2000 and 2018 were analyzed in terms of gender, age, subtypes and pathological T stages of RCC, side and size of pulmonary metastases, disease-free interval (DFI) and type of lung resections in order to reveal the prognostic factors from the stand point of selecting suitable patients for lung metastasectomy.

Results: Overall survival was 56.2 ±21.7 months. Survival time was less than 3 years for 7 (14.6%) , between 3 and 5 years for 11 (22.9%) and more than 5 years for 30 (62.5%) patients.  Young age, female gender, unilateral pulmonary lesions,  longer DFI, lung metastases limited in number and volume were statistically significant for better survival rates (P <.05) whereas subtypes and pathological stage of the primary tumor or the type of pulmonary metastasectomy did not act on the outcomes (P >.05).

Conclusion: The most distinctive factor affecting the surgical outcomes is the complete resection of lung metastases rather than the extent of the surgery. This study clearly states that patients aged under 50 years with unilateral lung metastases counting less than 3 and measuring smaller than 4 cm³  and also DFI lasting longer than 32 months  benefit from pulmonary metastasectomy of RCC.

Purpose: Germ cell tumors (GCTs) are rare and highly curable malignancies. However, salvage treatments for relapsed or refractory disease are needed in approximately 20-60% of the patients. As salvage therapy, autologous stem cell transplantation (ASCT) administered after high-dose chemotherapy (HDCT) may be a feasible option as well as standard dose chemotherapy (SDCT). This study aimed to evaluate the efficacy and toxicity of ASCT in salvage therapy of GCTs retrospectively. 

Materials and Methods: Male patients older than 18 years of age who underwent ASCT due to a relapsed/refractory GCT were included in the study.

Results: The median age of 18 patients included in the study was 28 (19-46). The majority of patients (n:16, 88.8%) had non-seminomatous GCT histology. All of the patients had relapsed or refractory GCTs and received bleomycin, etoposide, cisplatin (BEP) combination therapy previously. Half of the patients were in the poor risk group. ASCT was administered as a second-line therapy in 14 (77.7%) patients and third-line therapy in four (22.2%) patients. There is no ASCT-related exitus. Febrile neutropenia (FN) developed in almost all patients. Complete response (CR) was obtained in 7 (38.8%) patients, partial response (PR) in four (22.2%) patients after ASCT. The 2-year PFS was 44.4% and the median PFS was 8.7 (2.7-12.6) months. Median OS was 22.7 (3.9-41.7) months and 3 years OS was 50.0%.

Conclusion: In conclusion, ASCT was found to be an effective and safe treatment option in salvage therapy of GCT patients in our study.

Purpose:

Open surgical reimplantation of ureters is a highly successful procedure, with reported correction rates of 95 to 99 percent regardless of the severity of vesicoureteral reflux (VUR). Leadbetter-Politano ureteroneocystostomy is one of the most preffered technique for open ureteroneocystostomy. 

The authors report the modified Politano-Leadbetter technique with extravesical mobilization and transection of the ureter at the level of ureterovesical junction and intravesical reimplantation.

Materials and Methods:

Fifty-seven children with unilateral VUR, underwent modified Leadbetter-Politano ureteral reimplantation with extravesical mobilization and transection of the ureter at the level of ureterovesical junction and intravesical reimplantation. Persistence of VUR despite endoscopic correction, breakthrough infections, complications due to antibiotics, progressive renal scarring, reflux nephropathy, and parental preference were indications for open reimplantation. Operations were done by two full-time pediatric surgeons. Operation time and hospital stay of the patients, reflux persistency, voiding dysfunction and complications were recorded. 

Results:

No ipsilateral VUR was detected postoperatively. Mean operation time was 76.54 min (±8.76 min; range, 70-86 min) Mean duration of the hospital stay is 82.31 h (±9.78 h; range, 71-93 h). Postoperative gross hematuria was not seen in any patients. No voiding dysfunction and no late complications was encountered. 

Conclusions:

Modified Leadbetter-Politano technique is a good option to treat VUR with success rate up to 100% without any major complicatons such as viscus perforation and ureteral obstruction. It is a rather simple technique that require less operative time. 

Laparoscopic pyelolithotomy has recently been introduced for renal stones. However, the use of this technique is limited in patients with history of extensive abdominal surgeries. We present a case of right side staghorn renal stone with history of abdominal open cystectomy who underwent laparoscopic pyelolithotomy with uneventful outcome.

Traditionally, the standard treatment of bladder-prostate rhabdomyosarcoma (BP-RMS) is being implemented to be total cystoprostatectomy and urinary diversion. However, current multimodal treatment approaches emphasize the importance of bladder-sparing surgery.

In this case series, it was aimed to indicate the results of the laparoscopic bladder-sparing approach of two pediatric patients with BP RMS. They have admitted to the emergency department due to acute urinary retention (AUR). The tumors located in the prostate causing AUR were detected by Magnetic resonance imaging (MRI) and the pathological diagnosis was confirmed by biopsy. The patients were managed in a prosperous manner by implementing laparoscopic surgery with the cause of detection of a significant decrease in the size as well as the enhancement pattern of the tumors following neoadjuvant chemotherapy. No urinary incontinence, tumor recurrence or metastasis was observed at 36 and 28 months follow-up in case 1 and case 2, respectively.

Laparoscopic bladder-sparing approaches may have an advantage in patients with BP RMS to decrease morbidity and mortality related to radical surgery. To our knowledge, these are the first cases of laparoscopic bladder-sparing approach in the treatment of pediatric prostate-derived embryonal RMS (PDERMS).

Purpose: To evaluate the association between inflammation in prostatic tissue/serum sample and BPH-LUTS

Patients and methods: The prostatic tissue and serum sample were collected from 183 patients who underwent transurethral plasmakinetic resection of the prostate (TUPKRP).  The association between inflammation detected on prostatic tissues/ serum sample and LUTS related parameters, including International Prostate Symptom Score (IPSS) and peak flow rate (Qmax) were analyzed with SPSS version 13.0, and P-value <0.05 was chosen as the criterion for statistical significance.

Results: There was a positive association between prostate tissue inflammation and LUTS. The differences of IPSS, VSS and SSS were seen with the increasing in grade of prostate tissue inflammation (P<.001; .001; =.014, respectively). Qmax and IPSS 12months after surgery were better in no inflammation group (P=.016; .031).Logistic regression analysis revealed a statistically association between the NEUT%?NLR and prostate tissue inflammation (P=.010; .004), but ROC curve showed the NEUT%, NEUT and NLR area under curve (.526; .452; .513, respectively) were calculated as <0.600. Patients with Qmax over 7.12 had more WBC count in peripheral blood (7.56±1.77 VS 6.37±1.86, P=.026). The NLR was significantly higher in the group of IPSS over 20 and AUR presence (P=.018; .017).The NEUT%, LYMPH%, LYMPH and NLR showed a statistically significance in different obstruction classification (P=.047; .046; .028; .014, respectively).

Conclusion: There was correlation between chronic Inflammation and LUTS related to BPH. The patient without inflammation could acquire more sustained and steady relief than those with inflammation in LUTS related to BPH after TUPKRP.

Purpose: To analyze the predictive factors causing ischemic priapism following penile doppler ultrasonography (PDU) with intracavernosal papaverine injection

Materials and methods: Medical records of 467 patients who underwent PDU examination following intracavernosal papaverine injection for erectile dysfunction (ED) between 2009 and 2017 were retrospectively reviewed. Patients with hematological disease anamnesis, patients taking phosphodiesterase-5 inhibitor, patients with intracavernosal injection therapy anamnesis and patients who underwent PDU with other intracavernosal vasodilator drugs other than papaverine were excluded from the study. The remaining 268 patients were divided into two groups as priapism (38 patients) and non-priapism (230 patients). The groups were compared in terms of demographic data, American Society of Anesthesiologists (ASA) score, comorbidities, international index of erectile dysfunction (IIEF) score and PDU results. The significant parameters were analyzed with binary logistic regression analysis. The receiver operating analysis was used to obtain cut-off, sensitivity and specificity values for the independent predictive factors. 

Results: The age, ASA score, diabetes mellitus, IIEF score, duration of ED, peak arterial and peak end diastolic venous flow values in the 20th minute were significantly different in the two groups (p<0.001). Binary logistic regression analysis found age, duration of erectile dysfunction, IIEF score, peak arterial flow and venous flow rate in the 20th minute were predictive variables for the occurrence of priapism.

Conclusions: Young patients, patients with good IIEF score, patients with ED for a short time, and patients with normal peak arterial and venous flows are more prone to developing post-papaverine ischemic priapism.

Purpose: The present study was designed to compare the efficacy of alfuzosin therapy as an alpha-blocker in metabolic syndrome (MetS) and non-MetS patients with moderate lower urinary tract symptoms (LUTS).

Material and Methods: This prospective study included male patients with obstructive voiding and had a moderate LUTS according to International Prostate Symptom Score (IPSS). Patients were divided into two groups: MetS and Non-MetS. Following the measurement of uroflowmetric parameters (maximum flow rate [Qmax], post-void residual volume [PVR], urine volume) and the determination of IPSS scores, the patients were initiated on alfuzosin 10 mg once daily for a period of 12 weeks. At the end of the therapy, treatment outcomes were determined based on uroflowmetric parameters and IPSS scores.

Results: 301 patients were included in the study (MetS: 160, non-MetS: 141). Pre-treatment uroflowmetric measurements and IPSS scores were similar in both groups. After the therapy, the median Qmax level increased from 12.80 (10.62-14.82) ml/s to 14.55 (12.00-16.60) ml/s in the MetS group and from 12.60 (8.60-14.60) ml/s to 15.70 (13.20-17.20) ml/s in the non-MetS group (p<0.001 for both). Similar statistically significant changes were valid for PVR and IPSS. Post-treatment Qmax, PVR values and IPSS scores were higher in the non-MetS patients compared to MetS patients.

Conclusion: Although the non-MetS patients had greater benefit from the alfuzosin therapy compared to the MetS patients, alfuzosin is an effective alpha-blocker in the treatment of MetS patients with moderate LUTS. Based on these findings, it is tempting to consider that MetS might be a negative factor for benign prostate hyperplasia treatment.

We have studied up-to-date knowledge about the clinical feature of the Novel coronavirus pandemic worth consideration by the urologist. PubMed database, the United States centers for disease control and prevention (CDC), and the World Health Organization (WHO) websites were also accessed. A staging system introduced by Siddiqi et al. for the COVID-19 is acknowledged. Hemodialysis centers are high-risk zones in the outbreak of a COVID-19 epidemic. Symptoms and signs, clinical features, and laboratory findings of the renal transplant patients are almost similar to non-transplanted patients.

INTRODUCTION: On 11 March 2020, the World Health Organization (WHO) declared a pandemic. Since then hospitals have reduced inpatient and outpatient workflow and cancelled or suspended all non-emergent and routine surgical procedures. Our objective is to determine whether, during the COVID-19 period, there has been any modification in urological services.

MATERIALS AND METHODS: We retrospectively studied the data from January-May 2020 and 2019 about the variables: number of operations, waiting list, visits in outpatient department, bladder instillations and urological emergencies and admission rates.

RESULTS: Cancer cases high-risk for stage progression and surgical emergencies, were elected to proceed directly to treatment. The number of the operations was reduced by 43-65% from March-May 2020. Our surgical list had a waiting time of 6-8 weeks before the pandemic and now the waiting time has expanded to 12 weeks. Urological emergencies were reduced about 23-57%. Admission rates were dropped 10-51%. Visits in outpatient clinics were reduced 100-50% and outpatient procedures for elective cases were all deferred. Unfortunately, the hospital did not offer synchronous telehealth appointments. Bladder instillations of BCG or chemotherapeutics were not suspended but start of new cases had a delay of 2-3 weeks. There were no cases of COVID-19 in our department.

CONCLUSION: All the variables of our urologic practice were affected during the COVID era. The impact of the reduced model of outpatient and inpatient workflow on the health of our patients is unknown. However, longer waiting lists are expected. It is obvious that healthcare providers should adopt a new healthcare model.

COVID-19 pandemic has affected more than a million people worldwide causing a public health crisis. Under these unique circumstances, urologists continue to provide essential healthcare services and support healthcare systems, by participating in the treatment of COVID-19(+) patients and sparing vital equipment and hospital beds. However, delivering medical care during the pandemic requires strategic planning for all surgical and outpatient activities. Proposed measures include rescheduling elective non-oncological surgeries and using a prioritization protocol for oncological surgeries according to hospital capacity. Following that, outpatient clinics could be partly replaced by telemedicine. Additionally, urologists should be trained in screening and treating patients with COVID-19 during their daily routine.  In order to efficiently provide their services, a management protocol for suspected or known COVID-19 urological patients should be implemented. Furthermore, preventive measures for the nosocomial dispersion of the virus and training on self-protective equipment is mandatory for all physicians. Finally, organizational planning for the best utilization of the staff is of utmost importance. Implementation and adaptation of the protocols according to local requirements and guidelines will ameliorate the quality of services and population’s health status. Finally, enhancement of current practices will prepare health systems for future crisis.

Since the emergence of Covid19 epidemics different guidelines and protocols have been published by Urology associations. Most of these recommendations have focused on the aptitude of any disease or condition for postponement. With the evolution of the outbreak, it is clear that postponement of procedures is not the policy we can rely on exclusively. We must know where do we stand? Where are we going in our country? How useful our recommendations have been for urology practitioners? We try to draw a clearer although-to some extent- conjectural picture and to adjust our protocols to this picture of outbreak evolution. Assuming that anything in this predicament is subject to unexpected changes.

For these goals, we raise these arguments in three sections. First, where do we stand and where are we going? Explaining the present situation and best available statistics of the disease, the velocity the disease is spreading and our approximate predicted date its subsidence or partial remission.

In a web form survey, we tried to evaluate that in the absence of a clear picture of outbreak progress in a specific area, how useful experts’ points of view will be for the urologists working in non-referral centers especially in relevance to equivocal and challenging cases. Will there be any significant difference at all?

In the third section, we try to give the plot to guide scheduling or postponing procedures in any given are according to the level of involvement. Here we considered both the characteristics of the special urology condition and also the situation and progress of the outbreak in that area

Introduction: Novel coronavirus Disease (Covid-19) has emerged in Wuhan, China in December 2019 and became a pandemic in a few weeks. In this review, we aimed to summarize the current urologic practice trends worldwide to help urologist in decision making in disasters particularly in Covid-19 pandemic.

Material and Method: We have performed a PubMed and Internet search by using the keywords: ‘Covid’, ‘new coronavirus’, ‘coronavirus urology, ‘covid urology’ without a date restriction. 

Results: All elective surgeries for benign urological conditions such as urinary tract stone disease that not caused complicated obstruction, benign prostate enlargement, infertility, incontinence and genitourinary prolapse, erectile dysfunction undescendent testis, vesico-ureteral reflux   should be postponed till the lasting of Covid-19 outbreak. In obstructing ureteral stone both nephrostomy tube and double-J stent insertion are valid management options. However, one must consider that these procedures must be performed under local anesthesia when possible to spare a ventilator. When deferring urooncological operations and treatments oncological outcomes must be considered. Aggressive cessation or reducing the dosage of immunosuppressant therapy might be an option in renal transplanted patients with severe pneumonia or acute respiratory distress syndrome.

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