## 4 Discussion
This transition may reflect both modified health-seeking behaviors and structural changes in outpatient access during the pandemic. The increase in preoperative stenting and the reduction in waiting times observed in our study reflect a successful institutional adaptation to the pandemic. This bridging strategy enabled symptom control while facilitating flexible scheduling amid constrained resources [1]. The five-tier urgency classification system proposed by Cleveland Clinic, categorizing infected or obstructing stones as Tier 0 (highest urgency), provided a useful framework for procedural triage [15]. Our approach aligns with recommendations from both international and domestic guidelines, including those by the European Association of Urology Rapid Reaction Group [16] and the Japanese Urological Association [17], which endorse preoperative stenting as a valid interim measure. Since stone size did not differ significantly between groups (Table 2), shorter operative times in the post-pandemic cohort may be largely due to the increased use of preoperative stenting. Numerous studies support the benefits of preoperative stenting. [PERSON] et al. conducted a meta-analysis demonstrating that double-J stenting significantly improves stone-free rates (odds ratio 1.60, 95% confidence interval [CI] 1.19-2.15, \(p\) = 0.002) [18]. [PERSON] et al. reported that stenting enhances access sheath insertion success (risk ratio 1.09, 95% CI 1.05-1.13, \(p\) < 0.00001) and reduces ureteral injury risk [19]. [PERSON] and [PERSON] introduced a triage framework based on disease severity [20], and [PERSON] et al. demonstrated improved-access sheath success rates with stenting (93.8% vs. 85.3%, \(p\) = 0.023) [21]. [PERSON] et al. further reported higher stone-free rates and lower complication rates among pre-stented patients, especially for proximal ureteral and renal pelvis stones [22]. This is consistent with [PERSON] et al. 's emphasis on temporizing strategies such as stents and neph prostomy in maintaining essential services [2]. [PERSON] et al. further supported the role of passive dilation in procedural success [23]. A salient finding of this study is that clinical outcomes remained stable, or even improved, despite the operational challenges posed by the pandemic. In our cohort, the number of presenting cases increased during the COVID-19 period. The observed reductions in operative time, while maintaining stone-free and complication rates, underscore the efficacy of adaptive clinical strategies. While a non-significant increase in patients with ECOG-PS \(\geq\)2 was noted post-pandemic, emergency urolithiasis care remained a clinical priority, in contrast to elective cases which may have been deferred. Our observations mirror institutional experiences at Cleveland Clinic, where in-person visits fell from 100% to 6%, replaced by virtual consultations, and delays in clinic visits increased from 7 days to 15 days (\(p<0.0001\)) [6]. Moreover, shifts in postoperative stent management were reported, with a marked increase in stentless procedures (12% to 66%) and the use of extraction strings for self-removal (7% to 16%) [6]. A global review by [PERSON] et al. described a 34% decline in elective urologic surgeries and a 9.3% decrease in emergency procedures during the pandemic [24]. This led to innovations such as increased use of stents with strings and stentless techniques [24]. The shortened surgical waiting time observed in our study likely contributed to maintaining favorable outcomes, even with higher stenting rates. [PERSON] et al. demonstrated that prolonged stent indwelling times increase the risk of post-ureteroscopy sepsis (1% for <1 month vs. 9.2% for >3 months) [25]. Additionally, [PERSON] et al. showed that long-term stents can substantially impair quality of life [26]. Our institution minimized stent duration, ensuring timely definitive surgery. Previous studies by [PERSON] et al. and [PERSON] et al.