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Ancha N, Eldin M, Woodle T, Gereta S, Hariprasad K, Butler I, Charles Osterberg E. Current devices, outcomes, and pain management considerations in penile implant surgery: an updated review of the literature. Asian J Androl 2024; 26:335-343. [PMID: 38376174 DOI: 10.4103/aja202386] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Accepted: 12/11/2023] [Indexed: 02/21/2024] Open
Abstract
Penile prosthesis surgery is a definitive treatment for erectile dysfunction (ED). The two categories of penile prosthesis are endorsed by professional guidelines, inflatable penile prosthesis (IPP) and malleable penile prosthesis (MPP). Each modality of penile prosthesis offers distinct advantages and incorporates specific design features, allowing for personalized device selection that aligns with individual needs and preferences. While the overall complication rate of penile implant surgery remains low, surgeons should maintain a high index of suspicion for complications in the perioperative time period. Multimodal analgesic regimens including nerve blocks and narcotic-free pathways should be administered to manage perioperative pain. Finally, the high patient satisfaction after penile prosthesis surgery underscores the success of this ED treatment option.
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Affiliation(s)
- Nirupama Ancha
- Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, TX 78712, USA
| | - Maya Eldin
- Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, TX 78712, USA
| | - Tarah Woodle
- Department of Urology, Brooke Army Medical Center, San Antonio, TX 78234, USA
| | - Sofia Gereta
- Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, TX 78712, USA
| | - Krishna Hariprasad
- Department of Molecular Biosciences, The University of Texas at Austin, Austin, TX 78712, USA
| | - Imani Butler
- Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, TX 78712, USA
| | - E Charles Osterberg
- Department of Surgery and Perioperative Care, University of Texas at Austin Dell Medical School, Austin, TX 78712, USA
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2
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Truong A, Yao L, Fleshner PR, Zaghiyan KN. Feasibility of opioid-free surgery for inflammatory bowel disease. Colorectal Dis 2023; 25:976-983. [PMID: 36718946 DOI: 10.1111/codi.16493] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/05/2022] [Revised: 11/16/2022] [Accepted: 01/01/2023] [Indexed: 02/01/2023]
Abstract
AIM Patients undergoing colorectal surgery or those with inflammatory bowel disease (IBD) are particularly at risk for opioid-related complications and progression to long-term opioid dependence. The aim of this work is to explore the real-world possibility of perioperative opioid avoidance in colorectal surgery and IBD. METHOD We conducted a retrospective analysis of patients aggregated from two prospective studies on multimodal postoperative pain control conducted at a single tertiary referral centre. All patients underwent major colorectal surgery with bowel resection. Patients with chronic preoperative opioid use were excluded. Opioid use was measured in oral morphine equivalents (OME) each postoperative day (POD) and cumulatively for the first 72 h. RESULTS Our cohort of 209 patients included 148 (71%) with IBD and 61 (29%) non-IBD patients. IBD patients required significantly more opioids cumulatively over the first 72 postoperative hours compared with non-IBD patients [median OME 77 mg (interquartile range 33-148 mg) vs. 4 mg (interquartile range 17-82 mg), respectively; p = 0.001]. Five percent of IBD patients achieved opioid-free postoperative pain control during the entire 72 h postoperative period compared with 12% of non-IBD patients. Only 7% of IBD patients avoided opioid use on POD 1 compared with 20% of non-IBD patients (p = 0.02); however the number of IBD patients increased to 16% on POD 2 then 40% on POD 3, closely resembling the non-IBD cohort at 49% (p = 0.22). CONCLUSION In the era of modern enhanced recovery protocols and minimally invasive techniques, we show that early postoperative opioid avoidance is feasible in a limited number of IBD patients after colorectal surgery.
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Affiliation(s)
- Adam Truong
- Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Lucille Yao
- Cedars-Sinai Medical Center, Los Angeles, California, USA
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Anderson DJ, Cao DY, Zhou J, McDonald M, Razzak AN, Hasoon J, Viswanath O, Kaye AD, Urits I. Opioids in Urology: How Well Are We Preventing Opioid Dependence and How Can We Do Better? Health Psychol Res 2022; 10:38243. [PMID: 36118983 PMCID: PMC9476236 DOI: 10.52965/001c.38243] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/09/2023] Open
Abstract
Urologic procedures (both open and minimally invasive) can cause pain due to the surgery itself, devices placed, and post-operative issues. Thus, pain management is important for every post-procedure recovery period. Opioid use post-surgery is common and often over-prescribed contributing to persistent use by patients. In this article, we review the extent of opioid use in pediatric urologic procedures, vasectomy, endourologic procedures, penile implantation, urogynecologic procedures, prostatectomy, nephrectomy, cystectomy, and scrotal/testicular cancer surgery. Generally, we have found that institutions do not have a standardized protocol with a set regimen to prescribe opioids, resulting in more opioids being prescribed than needed and patients not properly disposing of their unused prescriptions. However, many institutions recognize their opioid overuse and are implementing new multimodal opioid-sparing analgesics methods such as non-opioid peri-operative medications, minimally invasive robotic surgery, and nerve blocks or local anesthetics with varying degrees of success. By shedding light on these opioid-free methods and prescription protocols, along with improved patient education and counselling, we hope to bring awareness to institutions and decrease unnecessary opioid use.
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Affiliation(s)
| | - David Y Cao
- School of Medicine, Medical College of Wisconsin
| | - Jessica Zhou
- School of Medicine, Medical College of Wisconsin
| | - Matthew McDonald
- School of Medicine, Rocky Vista University College of Osteopathic Medicine
| | | | - Jamal Hasoon
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School
| | - Omar Viswanath
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School; Valley Anesthesiology and Pain Consultants, Envision Physician Services; Department of Anesthesiology, University of Arizona College of Medicine Phoenix; Department of Anesthesiology, Creighton University School of Medicine
| | - Alan D Kaye
- Department of Anesthesiology, Louisiana State University Health
| | - Ivan Urits
- Department of Anesthesia, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center, Harvard Medical School; Department of Anesthesiology, Louisiana State University Health Shreveport
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Myrga JM, Wu S, Gul ZG, Yu M, Sharbaugh DR, Mihalo J, Patnaik S, Vasan RV, Miller DT, Pere MP, Yabes JG, Jacobs BL, Davies BJ. Discharge Opioids are Unnecessary Following Radical Cystectomy. Urology 2022; 170:91-95. [PMID: 36055420 DOI: 10.1016/j.urology.2022.08.025] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2022] [Revised: 08/16/2022] [Accepted: 08/18/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To show that zero-opioid discharges after both open and robotic cystectomy are feasible and to examine the impact of zero-opioid discharges on patient interaction with the physician's office. MATERIALS AND METHODS 107 patients who underwent either open or robotic radical cystectomy from March 1, 2020 to December 30, 2020 were identified. Patient demographics, perioperative data, and 30 day pain related outcomes including phone calls, office visits, requests for pain medication, emergency department visits, and readmissions were abstracted from the chart. We then examined variables associated with a zero-opioid discharge. RESULTS Thirty-two patients were discharged with an opioid prescription (Median Oral Morphine Equivalents Prescribed = 90) and seventy-five were discharged without an opioid prescription. On regression analysis, age (OR 1.07, 95% CI [1.02-1.12]) and pathology (OR 0.36, 95% CI[0.14-0.9]) remained significantly associated with postoperative opioid prescriptions. There were no differences in the percent of patients presenting to the emergency department, being readmitted, calling the office, calling the office regarding pain, or requesting opioid prescriptions within thirty days of discharge, or the number of post-operative office visits (p> 0.05 for all). CONCLUSIONS Patients can safely be discharged home without opioids following cystectomy, regardless of robotic or open approach. Age and pathology are predictors of the need for an opioid prescription on discharge. These patients did not have increased follow-up visits, phone calls, or requests for pain medication.
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Affiliation(s)
- J M Myrga
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA.
| | - S Wu
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - Z G Gul
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - M Yu
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - D R Sharbaugh
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - J Mihalo
- University of Pittsburgh School of Medicine, Pittsburgh, PA
| | - S Patnaik
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - R V Vasan
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - D T Miller
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - M P Pere
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - J G Yabes
- Division of Internal Medicine, Department of Medicine, University of Pittsburgh, Pittsburgh, PA; Center for Research on Health Care, Department of Medicine, University of Pittsburgh, Pittsburgh, PA
| | - B L Jacobs
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
| | - B J Davies
- University of Pittsburgh School of Medicine, Department of Urology, Pittsburgh, PA
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5
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Malo-Manso A, Ramírez-Aliaga M, Sepúlveda-Haro E, Díaz-Crespo J, Escalona-Belmonte JJ, Guerrero-Orriach JL. Opioid-free anesthesia for open radical cystectomy in morbid obesity. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2022; 69:433-436. [PMID: 35869004 DOI: 10.1016/j.redare.2021.03.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/03/2021] [Indexed: 06/15/2023]
Abstract
Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through μ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.
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Affiliation(s)
- A Malo-Manso
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Biomédica de Málaga, Málaga, Spain.
| | - M Ramírez-Aliaga
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - E Sepúlveda-Haro
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - J Díaz-Crespo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain
| | - J J Escalona-Belmonte
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Biomédica de Málaga, Málaga, Spain
| | - J L Guerrero-Orriach
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, Spain; Instituto de Investigación Biomédica de Málaga, Málaga, Spain; Departamento de Pediatría y Farmacología, Universidad de Málaga, Málaga, Spain
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Cheung DC, Martin LJ, Jivraj NK, Clarke H, Gomes T, Wijeysundera DN, Diong C, Nayan M, Saarela O, Alibhai S, Komisarenko M, Fleshner NE, Kulkarni GS, Finelli A. Opioid Use after Nephrectomy for Kidney Cancer in Ontario: A Population-Based Study. Urology 2022; 164:118-123. [PMID: 35182588 DOI: 10.1016/j.urology.2022.02.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2021] [Revised: 01/09/2022] [Accepted: 02/03/2022] [Indexed: 12/26/2022]
Abstract
OBJECTIVE To compare the odds of early and prolonged post-operative opioid use in patients undergoing minimally invasive surgery (MIS) versus open surgery for nephrectomy. METHODS For opioid-naïve patients in Ontario who underwent nephrectomy for kidney cancer (1994-2017, n=7900), post-discharge opioid use was determined by prescriptions in the Ontario Drug Benefit database (age ≥65 years) and the Narcotics Monitoring System (all patients from 2012). Early opioid use was defined as ≥ 1 prescription 1-90 days after surgery. Two separate definitions of prolonged opioid use were examined: (1) prescription(s) for ≥ 60 days during post-operative days 90-365; (2) ≥ 1 prescriptions between both of: 1-90 days AND 91-180 days after surgery. Predictors of opioid use were assessed using multivariable generalized estimating equation logistic regression, accounting for surgeon clustering. RESULTS Overall, 67.4% of patients received early opioid prescriptions; however, prolonged use was low, ranging from 1.6 to 4.4% of patients depending on the definition. In multivariable analysis, open nephrectomy was associated with higher odds of early opioid use compared to MIS nephrectomy (Odds Ratio [OR] 1.36, 95% Confidence Interval [CI] 1.19-1.55). Surgery type was not significantly associated with prolonged opioid use for either definition (OR 1.22, CI 0.79 1.89 and OR 1.06, CI 0.83, 1.35). CONCLUSIONS In this population-level study of patients undergoing nephrectomy for kidney cancer, patients who received open surgery were at increased odds of receiving early post-operative opioids compared to MIS. Prolonged opioid use was low overall and was not significantly with associated with type of surgery.
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Affiliation(s)
- D C Cheung
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - L J Martin
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre-University Health Network, Toronto, Canada
| | - N K Jivraj
- Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada
| | - H Clarke
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, Toronto, Canada; Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada
| | - T Gomes
- Institute of Health Policy Management and Evaluation, University of Toronto; Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada; ICES, Toronto, Canada
| | - D N Wijeysundera
- Department of Anesthesiology and Pain Medicine, University of Toronto, Toronto, Canada; ICES, Toronto, Canada; Department of Anesthesia, St. Michael's Hospital, Toronto, Canada
| | | | - M Nayan
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada
| | - O Saarela
- Dalla Lana School of Public Health, University of Toronto, Toronto, Canada
| | - Smh Alibhai
- Department of Medicine, University Health Network, University of Toronto, Canada
| | - M Komisarenko
- Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre-University Health Network, Toronto, Canada
| | - N E Fleshner
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre-University Health Network, Toronto, Canada
| | - G S Kulkarni
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre-University Health Network, Toronto, Canada
| | - A Finelli
- Division of Urology, Department of Surgery, University of Toronto, Toronto, Canada; Division of Urology, Department of Surgical Oncology, Princess Margaret Cancer Centre-University Health Network, Toronto, Canada.
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Lee G, Patel HV, Srivastava A, Ghodoussipour S. Updates on enhanced recovery after surgery for radical cystectomy. Ther Adv Urol 2022; 14:17562872221109022. [PMID: 35844831 PMCID: PMC9280843 DOI: 10.1177/17562872221109022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Accepted: 06/07/2022] [Indexed: 12/24/2022] Open
Abstract
Enhanced Recovery after Surgery (ERAS) is a multimodal pathway that provides evidence-based guidance for improving perioperative care and outcomes in patients undergoing surgery. In 2013, the ERAS society released its original guidelines for radical cystectomy (RC) for bladder cancer (BC), adopting much of its supporting data from colorectal literature. In the last decade, growing interest in ERAS has increased RC-specific ERAS research, including prospective randomized controlled trials (RCTs). Collective data suggest ERAS contributes to improved complication rates, decreased hospital length-of-stay, and/or time to bowel recovery. Various institutions have adopted modified versions of the ERAS pathway, yet there remains a lack of consensus on the efficacy of specific ERAS items and standardization of the protocol. In this review, we summarize updated evidence and practice patterns of ERAS pathways for RC since the introduction of the original 2013 guidelines. Novel target interventions, including use of immunonutrition, prehabilitation, alvimopan, and methods of local analgesia are reviewed. Finally, we discuss barriers to implementing and future steps in advancing the ERAS movement.
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Affiliation(s)
- Grace Lee
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Hiren V Patel
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Arnav Srivastava
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Saum Ghodoussipour
- Section of Urologic Oncology, Rutgers Cancer Institute of New Jersey and Rutgers Robert Wood Johnson Medical School, 195 Little Albany Street, Room 4561, New Brunswick, NJ 08903, USA
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Abaza R, Kogan P, Martinez O. Narcotic Avoidance After Robotic Radical Cystectomy Allows Routine of Only Two-Day Hospital Stay. Urology 2021; 161:65-70. [PMID: 34968571 DOI: 10.1016/j.urology.2021.10.049] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2021] [Revised: 10/22/2021] [Accepted: 10/31/2021] [Indexed: 11/17/2022]
Abstract
OBJECTIVE To evaluate the outcomes of a narcotic-sparing clinical pathway after robotic-assisted radical cystectomy (RARC) with ileal conduit targeting discharge on postoperative day #2 and report postoperative narcotic consumption, pain scores, and the resulting length of stay (LOS). METHODS We reviewed a single-surgeon series of consecutive RARCs between August 2015-September 2020. Acetaminophen and ketorolac were given with thorough patient education reserving oral narcotics for breakthrough pain. Intravenous narcotics were intentionally excluded from postoperative orders. Alvimopan was given once it became available. Subcutaneous ropivacaine pain pumps were removed before discharge. Discharge criteria included diet, oral analgesia, ambulation, and bowel function. Narcotic use and pain scores were evaluated to deternine the success of the applied narcotic-avoidance strategy. RESULTS None of the 54 patients required intravenous narcotics postoperatively, and 19 patients (35%) never required even oral narcotics. Mean pain scores were higher in patients who required oral narcotics (4.3/11 vs 3.0/11, p=0.001, respectively). Among 35 patients who received narcotics, mean tablets taken were 4.3/day (range, 1-13) with 68% using 8 or less tablets during their entire LOS. Mean LOS was 2.1d (range 1-4). Five patients (9%) were discharged on POD#1, 37/54 (68.5%) on POD #2, 10/54 (18.5%) on POD#3 and 2/54 (4%) on POD #4. Eight patients (15%) were readmitted within 90 days. CONCLUSION Minimizing narcotics after RARC with conduit allowed for a 2-day LOS in the majority of patients and the shortest ever reported mean LOS after cystectomy, essentially halving hospitalization time. Patient education is critical to minimizing narcotic usage.
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Affiliation(s)
- Ronney Abaza
- Central Ohio Urology Group, LLC, Columbus, Ohio, USA.
| | - Paul Kogan
- Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio, USA
| | - Oscar Martinez
- Robotic Surgery, OhioHealth Dublin Methodist Hospital, Dublin, Ohio, USA
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Beksac AT, Wilson CA, Lenfant L, Kim S, Aminsharifi A, Zeinab MA, Kaouk J. Single-Port Mini-Pfannenstiel Robotic Pyeloplasty: Establishing a Non-Narcotic Pathway Along with A Same-Day Discharge Protocol. Urology 2021; 160:130-135. [PMID: 34710396 DOI: 10.1016/j.urology.2021.10.013] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Revised: 10/10/2021] [Accepted: 10/14/2021] [Indexed: 01/08/2023]
Abstract
OBJECTIVE To analyze the feasibility of a same day discharge protocol following SP robotic pyeloplasty. PATIENTS AND METHODS From a single institution series, 23 patients (12 multi-port (MP), 11 single-port (SP)) who underwent primary robotic dismembered pyeloplasty between February 2018 and March 2021 were analyzed. The association between baseline and perioperative characteristics with functional outcome was analyzed using, chi-square, Fisher's exact, Mann Whitney U and t-tests. RESULTS All SP cases were completed using the mini Pfannenstiel incision without the need for conversion or additional ports. Baseline characteristics were comparable. No intraoperative complications were seen. Only one patient in the SP group had a Clavien II complication. All patients in the MP group had a drain placed, whereas drain was not placed in the SP group. Length of stay was shorter in the SP group (11.4 vs. 42.6 hours, p<0.001). Although visual analog pain score was comparable at discharge (p=0.633), the SP group had lower opioid usage (morphine milligram equivalent) in the hospital (p<0.001) and a lower rate of opioid prescription during discharge (18.2% vs. 91.7% p<0.001). At a median follow-up of 8 months, no patients had flank pain and all patients had good kidney drainage on follow-up images. CONCLUSIONS Single-port robotic dismembered pyeloplasty through a mini-Pfannenstiel access allows a same-day discharge protocol with minimal opiate use.
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Affiliation(s)
- Alp Tuna Beksac
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Clark A Wilson
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Louis Lenfant
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Soodong Kim
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ali Aminsharifi
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mahmoud Abou Zeinab
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jihad Kaouk
- Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA.
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Malo-Manso A, Ramírez-Aliaga M, Sepúlveda-Haro E, Díaz-Crespo J, Escalona-Belmonte JJ, Guerrero-Orriach JL. Opioid-free anesthesia for open radical cystectomy in morbid obesity. REVISTA ESPANOLA DE ANESTESIOLOGIA Y REANIMACION 2021; 69:S0034-9356(21)00134-1. [PMID: 34565571 DOI: 10.1016/j.redar.2021.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Revised: 02/17/2021] [Accepted: 03/03/2021] [Indexed: 10/20/2022]
Abstract
Opioid-free anaesthesia shows evidence about its efectivity and security, even though its risks and benefits are not well defined. Neither are the patient profile or sort of surgery where it could be superior to the conventional opioid-based anaesthetic technique. Aggressive and/or long-lasting surgeries set out several queries on this technique regarding sudden hemodynamic changes, as it does not produce sympatholysis through μ receptor and there is modest experience in this technique. A morbidly obese patient received open radical cystectomy with Bricker-type urinary diversion using infraumbilical incision under OFA protocol, maintaining an adequate hemodynamic stability and excellent analgesia in postoperatory care without using any intraoperative opioids. Opioid-free anaesthesia technique is developing its evidence. However, it is necessary to keep on researching its clinical applications, different drug combinations and solutions to its expected complications.
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Affiliation(s)
- A Malo-Manso
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, Málaga, España.
| | - M Ramírez-Aliaga
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, Málaga, España
| | - E Sepúlveda-Haro
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - J Díaz-Crespo
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España
| | - J J Escalona-Belmonte
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, Málaga, España
| | - J L Guerrero-Orriach
- Servicio de Anestesiología y Reanimación, Hospital Universitario Virgen de la Victoria, Málaga, España; Instituto de Investigación Biomédica de Málaga, Málaga, España; Departamento de Pediatría y Farmacología, Universidad de Málaga, Málaga, España
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Current application of the enhanced recovery after surgery protocol for patients undergoing radical cystectomy: lessons learned from European excellence centers. World J Urol 2021; 40:1317-1323. [PMID: 34076754 DOI: 10.1007/s00345-021-03746-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2021] [Accepted: 05/25/2021] [Indexed: 10/21/2022] Open
Abstract
PURPOSE There is no consensus on which items of Enhanced Recovery After Surgery (ERAS) should and should not be implemented in radical cystectomy (RC). The aim of this study is to report current practices across European high-volume RC centers involved in ERAS. METHODS Based on the recommendations of the ERAS society, we developed a survey with 17 questions that were validated by the Young Academic Urologists-urothelial group. The survey was distributed to European expert centers that implement ERAS for RC. Only one answer per-center was allowed to keep a representative overview of the different centers. RESULTS 70 surgeons fulfilled the eligibility criteria. Of note, 28.6% of surgeons do not work with a referent anesthesiologist and 25% have not yet assessed the implementation of ERAS in their center. Avoiding bowel preparation, thromboprophylaxis, and removal of the nasogastric tube were widely implemented (> 90%application). On the other hand, preoperative carbohydrate loading, opioid-sparing anesthesia, and audits were less likely to be applied. Common barriers to ERAS implementation were difficulty in changing habits (55%), followed by a lack of communication across surgeons and anesthesiologist (33%). Responders found that performing a regular audit (14%), opioid-sparing anesthesia (14%) and early mobilization (13%) were the most difficult items to implement. CONCLUSION In this survey, we identified the ERAS items most and less commonly applied. Collaboration with anesthesiologists as well as regular audits remain a challenge for ERAS implementation. These results support the need to uniform ERAS for RC patients and develop strategies to help departments implement ERAS.
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12
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Ellis JL, Sudhakar A, Simhan J. Enhanced recovery strategies after penile implantation: a narrative review. Transl Androl Urol 2021; 10:2648-2657. [PMID: 34295750 PMCID: PMC8261412 DOI: 10.21037/tau-20-1220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2020] [Accepted: 11/02/2020] [Indexed: 12/03/2022] Open
Abstract
Optimizing pain management strategies in penile implantation has historically been a challenge to urologists assuming care of patients post-operatively. In addition to the complex pathophysiology of male genital pain, the responsibility of opioid stewardship in the face of the ongoing narcotics epidemic presents its own set of challenges to experienced implanters. Recent innovations in pre- and intra-operative analgesia have provided some improvement in patient-reported pain outcomes. When used together in protocols spanning each phase of operative care, multimodal analgesia (MMA) regimens provide superior patient pain control and successfully decrease opioid usage compared to traditional opioid-based pain control. This review will systematically present literature that discusses interventions in the preoperative and intraoperative spaces aimed at optimally controlling pain. We will also highlight surgical techniques that have been demonstrated to help ameliorate post-operative pain in penile implant recipients. We will discuss the impact of MMA protocols across urology and further explore its larger impact on reducing opioid burden in the ongoing epidemic.
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Affiliation(s)
- Jeffrey L Ellis
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Architha Sudhakar
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA
| | - Jay Simhan
- Department of Urology, Einstein Healthcare Network, Philadelphia, PA, USA.,Division of Urologic Oncology, Fox Chase Cancer Center, Philadelphia, PA, USA
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13
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Marcq G, Kassouf W. Postoperative ileus: A systematic pathway for radical cystectomy candidates? Can Urol Assoc J 2021; 15:40-41. [PMID: 33556310 DOI: 10.5489/cuaj.7134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Gautier Marcq
- Division of Urology, McGill University Health Centre, McGill University, Montreal, QC, Canada.,Univ. Lille, CNRS, Inserm, CHU Lille, Institut Pasteur de Lille, Lille, France.,Urology department, Claude Huriez Hospital, Lille, France
| | - Wassim Kassouf
- Division of Urology, McGill University Health Centre, McGill University, Montreal, QC, Canada
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14
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Pfail JL, Garden EB, Gul Z, Katims AB, Rosenzweig SJ, Razdan S, Omidele O, Nathaniel S, Loftus K, Sim A, Mehrazin R, Wiklund PN, Sfakianos JP. Implementation of a nonopioid protocol following robot-assisted radical cystectomy with intracorporeal urinary diversion. Urol Oncol 2021; 39:436.e9-436.e16. [PMID: 33495119 DOI: 10.1016/j.urolonc.2021.01.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Revised: 12/01/2020] [Accepted: 01/03/2021] [Indexed: 12/13/2022]
Abstract
PURPOSE The implementation of robot-assisted radical cystectomy (RARC) with intracorporeal urinary diversion (ICUD) for management of patients with muscle-invasive or high-risk noninvasive bladder cancer has increased in utilization over the last decade. Here, we seek to describe institutional opioid prescription and utilization patterns following implementation of a nonopioid (NOP) perioperative pain management protocol in patients who received RARC with ICUD. MATERIALS AND METHODS The records of all patients who underwent RARC that utilized a NOP perioperative pain management protocol at a single academic institution from 2016 to 2020 were retrospectively reviewed. Descriptive statistical analyses were performed. For comparison, we included 74 consecutive patients who received the same NOP protocol with extracorporeal urinary diversion (ECUD). RESULTS A total of 116 patients who received ICUD were included in our analysis. The median operation time for the ICUD group was 305 minutes (interquartile range [IQR]: 262-352). 12.1% (n = 14) of patients who underwent ICUD required narcotics during inpatient hospitalization. For these patients, the median morphine milligram equivalent requirement was 52.0 (IQR: 7.62-157). Additionally, only 12.1% (n = 14) of patients were prescribed opioids postoperatively at discharge. We identified that within 6 months of surgery only 5 (4.3%) patients required a second narcotic prescription. Furthermore, of patients who did not use mu-opioid blockers, a minority experienced postoperative ileus (15.7%, n = 16). 30- and 90-day all Clavien complication rates for patients were 44.8% (n = 52) and 49.1% (n = 57), respectively. Nineteen (16.4%) patients were readmitted within 30 days of discharge, of which none were pain related. When compared to ECUD, patients who received ICUD experienced similar complication and readmission rates. CONCLUSIONS The implementation of a NOP protocol for patients undergoing RARC with ICUD allows for both decreased postoperative narcotic use and reduced need for narcotic prescriptions at discharge with acceptable complication and readmission rates.
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Affiliation(s)
- John L Pfail
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Evan B Garden
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zeynep Gul
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Andrew B Katims
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Shirin Razdan
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Olamide Omidele
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sarah Nathaniel
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Katherine Loftus
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn school of Medicine at Mount Sinai, New York, NY
| | - Alan Sim
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn school of Medicine at Mount Sinai, New York, NY
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter N Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
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15
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Radical Cystectomy. Bladder Cancer 2021. [DOI: 10.1007/978-3-030-70646-3_14] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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16
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Kelley JJ, Hill S, Deem S, Hale NE. Post-Operative Opioid Prescribing Practices and Trends Among Urology Residents in the United States. Cureus 2020; 12:e12014. [PMID: 33457121 PMCID: PMC7797457 DOI: 10.7759/cureus.12014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Introduction: With the opioid epidemic escalating across the country, we sought to evaluate and characterize post-operative opioid prescribing habits and trends among urology residents in the United States. Methods: Urology residents were sent a 16-question survey regarding opioid prescribing patterns, influencing factors, opioid training experience, and amounts of opioids prescribed for common urologic procedures. Results: One hundred and four urology residents participated in the survey (75% male and 25% female). Common factors influencing opioid prescribing were standard prescribing practice for certain operations (80%), attending/senior resident preference (62.1%), and immediate post-operative pain (54.7%). Residents reported prescribing more opioids at discharge for open abdominal and robotic procedures (167.9 and 134.2 morphine milligram equivalents, MME, respectively) and lower amounts for outpatient surgeries (39.7 and 55.8 MME for vasectomy and transurethral resections). Only 15.5% of residents utilize any formal algorithm for post-operative opioid prescribing at their institution. Further, 51.6% of residents received no formal education on safe opioid prescribing during residency, and only 42.1% routinely assess patient risk for opioid abuse. Urology residents who received formal opioid training prescribed less opioids on average for common urologic procedures compared to those who had not trained. Conclusions: This study highlights the importance of increasing resident education on opioid prescribing during residency training, as well as an opportunity for the implementation of standardized post-operative opioid prescribing regimens to help improve trends in urology resident opioid prescribing.
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Affiliation(s)
- James J Kelley
- Urology, Charleston Area Medical Center, Charleston, USA
| | - Sharon Hill
- Urology, Charleston Area Medical Center, Charleston, USA
| | - Samuel Deem
- Urology, Charleston Area Medical Center, Charleston, USA
| | - Nathan E Hale
- Urology, Charleston Area Medical Center, Charleston, USA
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17
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Schmidt B, Bhambhvani HP, Greenberg DR, Prado K, Shafer S, Thong A, Gill H, Skinner E, Shah JB. Bupivacaine local anesthetic to decrease opioid requirements after radical cystectomy: Does formulation matter? Urol Oncol 2020; 39:369.e1-369.e8. [PMID: 33303378 DOI: 10.1016/j.urolonc.2020.11.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/21/2020] [Accepted: 11/04/2020] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Reduction of opioids is an important goal in the care of patients undergoing radical cystectomy (RC). Liposomal bupivacaine (LB) has been shown to be a safe and effective pain reliever in the immediate postoperative period and has been reported to reduce postoperative opioid requirements. Since the liposomal formulation is predicated on slow systemic absorption, the amount of bupivacaine administered is notably higher than that typically used with standard bupivacaine (SB) formulations. In addition, LB is costly, not universally available, and studies comparing this formulation to SB are lacking. We sought to determine if there is a difference in postoperative opioid requirements in patients who receive LB vs. high dose SB at the time of RC. METHODS In May 2019 we transitioned to administration of high-volume SB injected intraoperatively at the time of RC. This prospective cohort was compared to a historical cohort of patients who received injection of LB at the time of surgery. Primary endpoints included postsurgical opioid use measured in morphine equivalent dose (MED) and patient-reported Numeric Rating Scale (NRS) pain scores and length of stay. All patients were managed using principles of enhanced recovery after surgery (ERAS). RESULTS From May 2019 through August 2019, 28 patients underwent RC and met eligibility criteria to receive SB at the time of surgery. They were compared to a historical cohort of 34 patients who received LB between November 2017 and July 2018. There was no difference in MED exposure either in the postanesthesia care unit (SB 9.0 ± 8.9 MED vs. LB 6.5 ± 9.4 MED, P= 0.29) or during the remainder of the hospital stay (SB 36.8 ± 56.9 MED vs. LB 42.1 ± 102.5 MED, P= 0.81), no difference in NRS pain scores on postoperative day 1 (SB 2.6 ± 1.6 vs. LB 2.1 ± 1.7, P= 0.23), day 2 (SB 2.4 ± 1.8 vs. LB 1.9 ± 1.6, P= 0.19), or day 3 (SB 1.9 ± 1.8 vs. LB 1.7 ± 1.7, P= 0.69) and no difference in length of stay (SB 5.0 ± 1.7 days, LB 4.9 ± 3.3 days, P= 0.93). Subgroup analysis of open RC and robotic-assisted RC showed no significant difference in MED or pain scores between LB and SB patients. CONCLUSIONS Among patients undergoing RC under ERAS protocol there was no significant difference in postoperative opioid consumption, NRS pain scores, or length of stay among patients receiving SB compared to LB.
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Affiliation(s)
- Bogdana Schmidt
- Department of Urology, Stanford University School of Medicine, Stanford, CA.
| | | | - Daniel R Greenberg
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Kris Prado
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Steven Shafer
- Department of Anesthesiology, Stanford University School of Medicine, Stanford, CA
| | - Alan Thong
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Harcharan Gill
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Eila Skinner
- Department of Urology, Stanford University School of Medicine, Stanford, CA
| | - Jay B Shah
- Department of Urology, Stanford University School of Medicine, Stanford, CA
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18
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Serrell EC, Greenberg CC, Borza T. Surgeons and perioperative opioid prescribing: An underappreciated contributor to the opioid epidemic. Cancer 2020; 127:184-187. [PMID: 33002194 DOI: 10.1002/cncr.33199] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Emily C Serrell
- Department of Urology, University of Wisconsin, Madison, Wisconsin
| | - Caprice C Greenberg
- Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
| | - Tudor Borza
- Department of Urology, University of Wisconsin, Madison, Wisconsin.,Department of Surgery, University of Wisconsin, Madison, Wisconsin.,Wisconsin Surgical Outcomes Research Program, University of Wisconsin, Madison, Wisconsin
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19
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Pfail JL, Katims AB, Gul Z, Rosenzweig SJ, Razdan S, Nathaniel S, Martini A, Mehrazin R, Wiklund PN, Loftus K, Sim A, DeMaria S, Sfakianos JP. Can anesthetics affect bladder cancer recurrence? Total intravenous versus volatile anesthesia in patients undergoing robot-assisted radical cystectomy: A single institution retrospective analysis. Urol Oncol 2020; 39:233.e1-233.e8. [PMID: 32951989 DOI: 10.1016/j.urolonc.2020.08.024] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2020] [Revised: 08/04/2020] [Accepted: 08/14/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Radical cystectomy is standard of care and part of a multidisciplinary approach for long-term survival in patients with muscle-invasive bladder cancer (MIBC) or high-grade non-MIBC. Recent data have suggested that anesthetic technique can affect long-term survival and recurrence in patients undergoing cancer related surgery. METHODS The records of all patients who underwent robot-assisted radical cystectomy for high-risk non-MIBC or MIBC at a single academic institution from 2014 to 2020 were retrospectively reviewed. Patients were grouped according to whether they received total intravenous (TIVA) or volatile inhalation anesthesia (VIA). Univariable and multivariable cox proportional hazards models were used to compare hazard ratios for distant recurrence. Kaplan-Meier recurrence-free survival curves were constructed from the date of surgery to recurrence. RESULTS A total of 231 patients were included, of which 126 (55%) received TIVA and 105 (45%) received VIA. Distant recurrence occurred in 8.7% and 26.7% of patients who received TIVA and VIA, respectively (P < 0.001). Kaplan-Meier analysis demonstrated significant improvement in distant recurrence-free survival with TIVA (log-rank P < 0.001). Multivariable analysis revealed a significant increase in recurrence risk with VIA (HR: 3.4, 95%CI: 1.5-7.7, P < 0.01) and increasing tumor pathological stage (pT2, pT3, pT4, all P < 0.05). CONCLUSIONS The use of volatile inhalation anesthetics during robot-assisted radical cystectomy may be associated with an increased risk of distant recurrence. Further studies will be necessary to validate these findings.
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Affiliation(s)
- John L Pfail
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY.
| | - Andrew B Katims
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Zeynep Gul
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | | | - Shirin Razdan
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Sarah Nathaniel
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alberto Martini
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Reza Mehrazin
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Peter N Wiklund
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Katherine Loftus
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn school of Medicine at Mount Sinai, New York, NY
| | - Alan Sim
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn school of Medicine at Mount Sinai, New York, NY
| | - Samuel DeMaria
- Department of Anesthesiology, Perioperative and Pain Medicine, Icahn school of Medicine at Mount Sinai, New York, NY
| | - John P Sfakianos
- Department of Urology, Icahn School of Medicine at Mount Sinai, New York, NY
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20
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Tips and tricks in achieving zero peri-operative opioid used in onco-urologic surgery. World J Urol 2020; 40:1343-1350. [PMID: 32556676 DOI: 10.1007/s00345-020-03305-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2020] [Accepted: 06/08/2020] [Indexed: 10/24/2022] Open
Abstract
PURPOSE To review non-opioid based protocols in urologic oncologic surgery and describe our institutional methods of eliminating peri-operative opioids. METHODS A thorough literature review was performed using PUBMED to identify articles pertaining to reducing or eliminating narcotic use in genitourinary cancer surgery. Studies were analyzed pertaining to protocols utilized in genitourinary cancer surgery, major abdominal and/or pelvic non-urologic surgery. RESULTS Reducing or eliminating peri-operative narcotics should begin with an institutionalized protocol made in conjunction with the anesthesia department. Pre-operative regimens should consist of appropriate counseling, gabapentin, and acetaminophen with or without a non-steroidal anti-inflammatory medications. Prior to incision, a regional block or local anesthetic should be delivered. Anesthesiologists may develop opioid-free protocols for achieving and maintaining general anesthesia. Post-operatively, patients should be on a scheduled regimen of ketorolac, gabapentin, and acetaminophen. CONCLUSION Eliminating peri-operative narcotic use is feasible for major genitourinary oncologic surgery. Patients not only have improved peri-operative outcomes but also are at significantly reduced risk of developing long-term opioid use. Through the implementation of a non-opioid protocol, urologists are able to best serve their patients while positively contributing to reducing the opioid epidemic.
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21
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Faraj KS, Tyson MD. AUTHOR REPLY. Urology 2020; 140:114. [DOI: 10.1016/j.urology.2019.12.060] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2019] [Accepted: 12/19/2019] [Indexed: 10/24/2022]
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22
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Abstract
PURPOSE OF REVIEW Surgeons have played a significant role in the current opioid epidemic through overprescribing practices in the postoperative setting. However, contemporary efforts have helped to decrease opioid excess, particularly in the field of urology. Minimally invasive surgery offers a unique avenue to address overuse of narcotics in the postoperative period given its emphasis on enhanced recovery. RECENT FINDINGS Historically, the majority of the literature characterizing postoperative opioid use and its reduction has focused on non-urological surgery. However, recent studies have shown that patients undergoing urologic procedures are prescribed opioids in a similar manner as patients in other surgical specialties. Reduction strategies have been implemented through the use of regional anesthesia, enhanced recovery after surgery pathways, and the development of procedure-specific opioid prescription recommendations. Patients undergoing urologic surgery experience the same risk of opioid misuse and abuse as patients undergoing other types of surgery. However, the wide use of minimally invasive urological surgeries including robotic surgery offers a unique opportunity to reduce postoperative opioid use through multimodal and interdisciplinary protocols and standardizing guidelines.
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Affiliation(s)
- Juan Serna
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA. .,Jordan Medical Education Center, 6th Floor, 3400 Civic Center Blvd., Building 421, Philadelphia, PA, 19104, USA.
| | - Ruchika Talwar
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
| | - Daniel J Lee
- Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA.,Division of Urology, Department of Surgery, Hospital of the University of Pennsylvania, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.,Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
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23
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Greenberg DR, Kee JR, Stevenson K, Van Zyl E, Dugala A, Prado K, Gill HS, Skinner EC, Shah JB. Implementation of a Reduced Opioid Utilization Protocol for Radical Cystectomy. Bladder Cancer 2020. [DOI: 10.3233/blc-190243] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND: Radical cystectomy (RC) often requires a prolonged course of opioid medications for postoperative pain management. We implemented a Reduced Opioid Utilization (ROU) protocol to decrease exposure to opioid medications. OBJECTIVE: To determine the impact of the ROU protocol on opioid exposure, pain control, inpatient recovery, and complication rates among patients who underwent RC. METHODS: The ROU protocol includes standardized recovery pathways, a multimodal opioid-sparing pain regimen, and improved patient and provider education regarding non-opioid medications. Opioid exposure was calculated as morphine equivalent dose (MED), and was compared between RC patients following the ROU protocol and patients who previously followed our traditional pathway. Opioid-related adverse drug events (ORADEs), pain scores, length of stay, and 90-day complications, readmission, and mortality were also compared between cohorts. RESULTS: 104 patients underwent RC, 54 (52%) of whom followed the ROU protocol. ROU patients experienced a statistically significant decrease in opioid exposure in the post-anesthesia care unit (p = 0.003) and during their postoperative recovery (85.7±21.0 MED vs 352.6±34.4 MED, p < 0.001). The ROU protocol was associated with a statistically significant decrease in ORADEs after surgery. There was no significant difference in average pain scores, length of stay, readmissions, or 90-day complication or mortality rates. CONCLUSIONS: The ROU protocol decreased opioid use by 77% without compromising pain control or increasing the rate of complications. This study demonstrates the efficacy of non-opioid medications in controlling postoperative pain, and highlights the role providers can play to decrease patient exposure to opioids after RC surgery.
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Affiliation(s)
- Daniel R. Greenberg
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jessica R. Kee
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Kerri Stevenson
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Elizna Van Zyl
- Stanford University Healthcare, Stanford University School of Medicine, Stanford, CA, USA
| | - Anisia Dugala
- Stanford University Healthcare, Stanford University School of Medicine, Stanford, CA, USA
| | - Kris Prado
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Harcharan S. Gill
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Eila C. Skinner
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
| | - Jay B. Shah
- Department of Urology, Stanford University School of Medicine, Stanford, CA, USA
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24
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Rodrigues Pessoa R, Urkmez A, Kukreja N, Baack Kukreja J. Enhanced recovery after surgery review and urology applications in 2020. BJUI COMPASS 2020; 1:5-14. [PMID: 35474909 PMCID: PMC8988792 DOI: 10.1002/bco2.9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2020] [Revised: 01/28/2020] [Accepted: 01/28/2020] [Indexed: 02/01/2023] Open
Abstract
Purpose: To explore enhanced recovery after surgery (ERAS) components and their current application to major urologic surgeries, barriers to implementation and maintenance of the associated quality improvement. Data Identification: An English language literature search was done using PubMed. Study Selection: After independent review, 55 of the original 214 articles were selected to specifically address the stated purpose. Data Extraction: Clinical trials were included, randomized trials were prioritized, but robust observational studies were also included. Results of Data Synthesis: Many ERAS components have good data to support usage in radical cystectomy (RC) patients. Most ERAS programs include multidisciplinary teams carrying out multimodal pathways to hasten recovery after a major operation. ERAS components generally include preoperative counseling and medical optimization, venous thromboembolism prophylaxis, ileus prevention, avoidance of fluid overload, normothermia maintenance, early mobilization, pain control and early feeding, all leading to early discharge without increased complications or readmissions. Although there may not be specific data pertaining to other major urologic operations, the principles remain similar and ERAS is easily applicable. Conclusion: The benefits of ERAS programs are well established for RC and principles are easily applicable to other major urology operations. Barriers to implantation and maintenance of ERAS must be recognized to continue to maintain the benefits of these programs.
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Affiliation(s)
| | - Ahmet Urkmez
- Department of Urology University of Texas MD Anderson Cancer Center Houston TX USA
| | - Naveen Kukreja
- Department of Anesthesia University of Colorado Aurora CO USA
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25
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Pekala KR, Jacobs BL, Davies BJ. The Shrinking Grey Zone of Postoperative Narcotics in the Midst of the Opioid Crisis: The No-opioid Urologist. Eur Urol Focus 2019; 6:1168-1169. [PMID: 31563546 DOI: 10.1016/j.euf.2019.08.014] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2019] [Accepted: 08/21/2019] [Indexed: 02/05/2023]
Abstract
In urology, whether a surgeon needs to prescribe narcotics after minimally invasive surgery used to be a grey zone. We no longer believe that it is necessary to give opioids to opioid-naïve patients undergoing minimally invasive urologic surgery, with few exceptions.
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Affiliation(s)
- Kelly R Pekala
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA.
| | - Bruce L Jacobs
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Benjamin J Davies
- Department of Urology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
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26
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Engel D, Furrer MA, Wuethrich PY, Löffel LM. Surgical safety in radical cystectomy: the anesthetist's point of view-how to make a safe procedure safer. World J Urol 2019; 38:1359-1368. [PMID: 31201522 DOI: 10.1007/s00345-019-02839-y] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Accepted: 06/03/2019] [Indexed: 12/21/2022] Open
Abstract
PURPOSE The aim of this review is to present an anesthesiological overview on surgical safety for radical cystectomy implementing the cornerstones of today's rapidly evolving field of perioperative medicine. METHODS This is a narrative review of current perioperative medicine and surgical safety concepts for major surgery in general with special focus on radical cystectomy. RESULTS The tendency for perioperative care and surgical safety is to consider it a continuous proactive pathway rather than a single surgical intervention. It starts at indication for surgery and lasts until full functional recovery. Preoperative optimization leads to superior outcome by mobilizing and/or increasing physiological reserve. Multidisciplinary teamwork involving all the relevant parties from the beginning of the pathway is crucial for outcome rather than an isolated specialist approach. This fact has gained importance in times of an ageing frail population and rising health care cost. We also present our 2019 Cystectomy Enhanced Recovery Approach for optimization of perioperative care for open radical cystectomy in a high caseload center. CONCLUSIONS With the implementation of in itself simple but crucial steps in perioperative medicine such as multimodal prehabilitation, safety checks, better perioperative monitoring and enhanced recovery concepts, even complex surgical procedures such as radical cystectomy can be performed safer. Emphasis has to be laid on a more global view of the patients' path through the perioperative process than on the surgical procedure alone.
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Affiliation(s)
- Dominique Engel
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, CH 3010, Bern, Switzerland
| | - Marc A Furrer
- Department of Urology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Patrick Y Wuethrich
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, CH 3010, Bern, Switzerland
| | - Lukas M Löffel
- Department of Anaesthesiology and Pain Medicine, Inselspital, University Hospital Bern, CH 3010, Bern, Switzerland.
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