In this case report we describe an unusual presentation of severe acute papillary necrosis in a COVID-19-positive patient. An emergency flexible ureteroscopy greatly helped in the establishment of the diagnosis. In the international literature, there is a paucity of intraoperative endoscopic images representing severe renal papillary necrosis. We present a case of severe acute renal papillary necrosis in a 49-year-old south-Asian, COVID-19-positive male patient who needed emergency urological intervention for macroscopic hematuria and urinary retention due to clot formation in the urinary bladder. The patient underwent emergency cystoscopy, clot evacuation, and by rigid and flexible ureteroscopy. The diagnosis was only confirmed in the postoperative period, retrospectively. Finally, the patient fully recovered due to the multidisciplinary management. Diagnosis of rare clinical entities can be sometimes challenging in the everyday routine practice. Having atypical clinical course, the surgeon should be prepared and sometimes must take responsible decisions promptly, even if needed intraoperatively, to manage unexpected findings in order to get the right diagnosis without compromising the patient’s safety.

Flexible Ureteroscopy (FURS) has become an integral aspect of the surgical armamentarium to treat intra-renal stones that are less than 2 cm in diameter. Despite the progress made with regards to the design of the flexible ureteroscopes, surgeons still need to work with suboptimal ergonomics, which may result in orthopedic complaints, which as a result lead to imperfect performance. Robotic- Assisted FURS with Avicenna Roboflex has provided significant improvement of ergonomics. The Super Pulse Thulium Fiber Laser (SPTFL) may be considered as a viable alternative to holmium laser in stone management. Coronavirus Disease- 19 (Covid-19) has been declared as a pandemic by the World Health Organization (WHO) on March 11, 2020. As a result, many hospitals have been converted to dedicated facilities to manage the Covid-19 patients. Urinary stone disease represents a benign condition, but in non-negligible number of cases, it can lead to potential severe septic complications that could increase the burden on emergency services. Many surgical specialties including urology has made short pathways for patient flow to decrease the contact with the patients which in turn will decrease the possibility of transmission of Covid-19. The use of new technologies such as Avicenna Roboflex and thulium fiber laser in Covid-19 positive patients when performing flexible ureteroscopy can minimize direct contact with the patient, expedite the procedure, while protecting the staff from getting Covid-19 infection.

Background: Thulium fiber laser technology has been shown to provide more power through a small fiber to enable faster stone fragmentation. In the Covid era, positive patients were postponed for a few weeks before any surgery to ensure their safety. However, with complete ureteric obstruction with large stones, delayed ureteroscopy and stone fragmentation could potentially compromise renal function. We aim to evaluate the Thulium Fiber Laser outcome as an alternative to holmium YAG laser as intracorporeal lithotripter in Covid-19 positive patients. Methods: From March-July 2020, during the peak of the corona outbreak, 11 COVID-19 positive patients were admitted through the emergency department with obstructing ureteric stones underwent urgent JJ stent insertion 2 weeks later from the initial surgery a definitive treatment offered. Results: The average age was 36+-11.7 years, all-male, all fit and healthy despite their Covid-19 status. The average stone size was 11+-3.1 mm with a volume of 395.8+-280 mm3 . The Hounsfield unit measurement was 1033.3+-57.7. Seven underwent short general anesthesia and 4 had spinal anesthesia. The average laser duration was of 593.9+-357.5 seconds, and the average stone ablation speed was 0.66+-0.19 mm3 /Sec. The overall stone- free rate was 90.9%. All 11 patients were discharged safely on the same day with only 1 patient readmitted with steinstrasse and underwent urgent ureteroscopy. None of our patients developed late complications. Conclusion: Using the Thulium laser technology allows for a quick and safe alternative to Holmium for fragmenting ureteric stones with a high stone-free rate.

No abstract