Initial Experience with Narcotic-Free Ureteroscopy: A Feasibility Analysis

Factors associated with unplanned clinical encounters for ureteral stent-related symptoms

BACKGROUND, INTRODUCTION AND AIM

Ureteral stent-related symptoms (USRS) often result in unplanned phone calls and ER visits. We hypothesize that patient factors can be identified to predict these unplanned encounters.

METHODS AND MATERIALS

Retrospective analysis of indwelling ureteral stent placements from 2014 to 2019 at a single institution by CPT code was performed. Patient demographics, discharge medications, and clinical factors were evaluated using multiple logistic regression with respect to postoperative telephone and emergency room (ER) encounters for USRS.

RESULTS

Of 374 patients, 75 (20.1%) had one or more encounters for USRS: 48 (12.8%) called the clinic and 39 (10.4%) returned to the ER. Chronic opioid use was predictive of calls to clinic and ER visits (OR 3.21 [CI 1.42-6.97], p < 0.01 and OR 3.64 [CI 1.45-8.98], p < 0.01). Survival analysis stratified by history of chronic opioid use and discharge opioid prescriptions demonstrated that opioid naïve patients receiving opioids at discharge had unplanned encounters sooner and more often [Calls p = 0.025, ER p = 0.041]), whereas patients with chronic opioid use returned to the ER sooner and more frequently when prescribed additional opioids (Calls p = 0.4, ER p = 0.002).

CONCLUSION

Patients with a history of chronic opioid use may experience more intense USRS or have a lower threshold to seek medical care than opioid naïve patients and tend to bypass calling the clinic for the ER. Given that none of the studied medications reduced unplanned patient contact for USRS, urologists should consider upfront definitive management of urinary obstruction when appropriate.

Nonopioid Pain Management Pathways for Stone Disease

Introduction: New opioid dependency after urologic surgery is a serious adverse outcome that is well-described in the literature. Patients with stone disease often require multiple procedures because of recurrence of disease and hence are at greater risk for repeat opioid exposures. Despite this, opioid prescribing after urologic surgery remains highly variable and in an emergency setting, opioids are still used commonly in management of acute renal colic. Methods: Two literature searches were performed using PubMed. First, we searched available literature concerning opioid-sparing pathways in acute renal colic. Second, we searched available literature for opioid-sparing pathways in ureteroscopy and percutaneous nephrolithotomy (PCNL). Abstracts were reviewed for inclusion in our narrative review. Results: In the setting of acute renal colic, multiple randomized control trials have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) attain greater reduction in pain scores, decreased need for rescue medications, and decreased vomiting events in comparison with opioids. NSAIDs also form a core component in management of postureteroscopy pain and have been demonstrated in randomized trials to have equivalent to improved pain control outcomes compared with opioids. Multiple opioid-free pathways have been described for postureteroscopy analgesia with need for rescue narcotics falling under 20% in most studies, including in patients with ureteral stents. Enhanced Recovery After Surgery protocols after percutaneous nephrolithotomy are less well described but have yielded a reduction in postoperative opioid requirements. Conclusions: In select patients, both acute renal colic and after kidney stone surgery, adequate pain management can usually be obtained with minimal or no opioid medication. NSAIDs form the core of most described opioid-sparing pathways for both ureteroscopy and PCNL, with the contribution of other components to postoperative pain outcomes limited because of lack of head-to-head comparisons. However, medications aimed specifically at targeting stent-related discomfort form a key component of most multimodal postsurgical pain management pathways. Further investigation is needed to develop pathways in patients unable to tolerate NSAIDs.

Opioid-free percutaneous nephrolithotomy: an initial experience

INTRODUCTION

The opioid epidemic in the United States is an ongoing public health crisis that is in part fueled by excessive prescribing by physicians. Percutaneous nephrolithotomy (PCNL) is a procedure that conventionally involves opioid prescriptions for adequate post-operative pain control. We aimed to evaluate the feasibility of a non-opioid pain regimen by evaluating post-operative outcomes in PCNL patients discharged without opioids.

MATERIALS AND METHODS

As a quality improvement measure to reduce opioid consumption our department began routinely prescribing oral ketorolac instead of oxycodone-acetaminophen for pain control after PCNL. We retrospectively compared patients undergoing PCNL who had received ketorolac prescriptions (NSAID) to those who received oxycodone-acetaminophen prescriptions (NARC). Demographic, operative, and post-operative factors were obtained and compared in both groups. Peri-operative factors and demographics were compared using either Chi-squared tests, Mann-Whitney U tests. Surgical outcomes were compared between the two groups using Chi-squared tests and Fisher's exact tests. Multivariate logistic regression analysis was performed to determine whether ketorolac use was an independent predictor of post-surgical pain-related encounters. Primary outcome was unplanned pain-related healthcare encounters inclusive of office phone calls, unscheduled office visits, and emergency department (ED) visits. Secondary outcome measures were non-pain-related healthcare encounters, hospital readmissions, pain-related rescue medications prescribed, and post-op complications.

RESULTS

There were similar demographics and peri-operative characteristics amongst patients in both cohorts. There was no significant difference identified between NSAID and NARC regarding unplanned pain-related encounters (8/70, 11.4% vs. 10/70, 14.3%, p = 0.614). However, NARC experienced more unplanned phone calls (42, 60% vs. 24, 34.3%, p = 0.004). Multivariate analysis revealed only prior stone surgery was predictive of pain-related encounters after PCNL (p = 0.035).

CONCLUSION

Our results show that there were no significant differences in pain-related encounters between those who received ketorolac and oxycodone-acetaminophen following PCNL. A non-opioid pathway may mitigate the potential risk associated with opioid prescription without compromising analgesia. Prospective comparative studies are warranted to confirm feasibility.

Perioperative Pain Management With Opioid Analgesics in Colpopexy Increases Risk of New Persistent Opioid Usage

IMPORTANCE

Although the use of perioperative pain medications is highly investigated, limited studies have examined the usage of pain medication for post hysterectomy prolapse repair and the few that have have been restricted to smaller sample sizes.

OBJECTIVE

Our objective was to assess the association of perioperative opioid usage after posthysterectomy prolapse repairs with development of new persistent opioid usage.

STUDY DESIGN

The TriNetX Diamond Research Network was queried to create our cohorts of opioid-naive adult women with vaginal repair or laparoscopic sacrocolpopexy. The primary study outcomes were (1) the rate of perioperative opioid usage and (2) development of new persistent opioid usage. All cohorts were matched on age, race, ethnicity, chronic kidney disease, hypertensive diseases, ischemic heart disease, diseases of the liver, obstructive sleep apnea, affective mood disorders, pelvic and perineal pain, obesity, tobacco use, and utilization of office/outpatient, inpatient, or emergency department services.

RESULTS

We identified 10,414 opioid-naive women who underwent laparoscopic sacrocolpopexy and 13,305 opioid-naive women who underwent vaginal reconstruction. Rates of perioperative opioid usage were higher after laparoscopic sacrocolpopexy. Rates of developing new opioid usage were higher in both surgical-approach populations that received perioperative opioids compared with those that did not. Rates of new and persistent opioid usage did not differ by surgical approach when stratified by perioperative opioid usage.

CONCLUSIONS

We identified that opioid dependence may occur after surgery if patients are given opioids within 7 days of either approach, associating opioid dependence with perioperative opioid usage rather than the approach taken.

Optimizing pain management following kidney stone surgery: can we avoid narcotics?

INTRODUCTION

Opioids are often used to manage postoperative pain. Non-narcotic alternatives have increasingly been used to reduce opioid usage. We conducted an open-label randomized non-inferiority clinical trial to compare non-opioid to opioid therapy for pain management after nephrolithiasis surgery.

METHODS

Patients undergoing elective ureteroscopy or percutaneous nephrolithotomy between July 2018 and May 2021 were randomized to receive ketorolac (non-opioid) or oxycodone-acetaminophen (opioid). Each patient was surveyed one week postoperatively to assess pain outcomes. Patient demographics, surgical variables, number of pills used, constipation, and adverse events were also assessed. We evaluated whether non-opioid analgesia was non-inferior to opioid analgesia for postoperative pain, assuming a non-inferiority margin of 1.3 in pain score between groups.

RESULTS

Analyses were based on 90 patients with postoperative pain data: 44 in the ketorolac group and 46 in the oxycodone-acetaminophen group. The groups were similar regarding demographics, type of surgery, ureteral stent placement, and stone burden. Non-inferiority of non-opioids compared to opioids was demonstrated for all outcomes. At follow-up, the average pain scores were 3.20 ± 1.94 (SD) in the non-opioid group and 4.17 ± 1.84 in the opioid group (difference =  - 0.96; 95% CI: - 1.76, - 0.17, p = 0.018). The mean proportions of unused pills were similar between groups (p = 0.47) as were rates of constipation (p = 0.32).

CONCLUSIONS

Non-opioid analgesia was non-inferior to opioid analgesia in pain management after kidney stone surgery. This trial contributes to the evidence that non-opioid analgesics should be considered an effective option for pain management following non-invasive urologic procedures.

Optimizing pain management following kidney stone surgery: can we avoid narcotics?

INTRODUCTION

Opioids are often used to manage postoperative pain. Non-narcotic alternatives have increasingly been used to reduce opioid usage. We conducted an open-label randomized non-inferiority clinical trial to compare non-opioid to opioid therapy for pain management after nephrolithiasis surgery.

METHODS

Patients undergoing elective ureteroscopy or percutaneous nephrolithotomy between July 2018 and May 2021 were randomized to receive ketorolac (non-opioid) or oxycodone-acetaminophen (opioid). Each patient was surveyed one week postoperatively to assess pain outcomes. Patient demographics, surgical variables, number of pills used, constipation, and adverse events were also assessed. We evaluated whether non-opioid analgesia was non-inferior to opioid analgesia for postoperative pain, assuming a non-inferiority margin of 1.3 in pain score between groups.

RESULTS

Analyses were based on 90 patients with postoperative pain data: 44 in the ketorolac group and 46 in the oxycodone-acetaminophen group. The groups were similar regarding demographics, type of surgery, ureteral stent placement, and stone burden. Non-inferiority of non-opioids compared to opioids was demonstrated for all outcomes. At follow-up, the average pain scores were 3.20 ± 1.94 (SD) in the non-opioid group and 4.17 ± 1.84 in the opioid group (difference =  - 0.96; 95% CI: - 1.76, - 0.17, p = 0.018). The mean proportions of unused pills were similar between groups (p = 0.47) as were rates of constipation (p = 0.32).

CONCLUSIONS

Non-opioid analgesia was non-inferior to opioid analgesia in pain management after kidney stone surgery. This trial contributes to the evidence that non-opioid analgesics should be considered an effective option for pain management following non-invasive urologic procedures.

A prospective randomized study evaluating the necessity of narcotics following ureteroscopy for urinary stone disease

PURPOSE

To evaluate the efficacy of non-narcotic analgesics and preoperative counseling in managing postoperative pain and narcotic use following ureteroscopic laser lithotripsy (URS).

METHODS

Adult patients at a single academic center undergoing URS for nephrourolithiasis were recruited. After informed consent, subjects were randomized into three groups: NARC-15 tablets oxycodone-acetaminophen 5/325 mg (A-OXY), 2. NSAID-15 tablets ibuprofen (IBU) 600 mg, 3. CNSL-15 tablets A-OXY, 15 tablets IBU, and preoperative counseling from the surgeon to avoid narcotic if possible. Patients who did not receive an intraoperative stent were excluded. At the time of stent removal subjects completed the Universal Stent Symptom Questionnaire (USSQ), and a pill count was performed. USSQ pain indices were the primary study endpoint.

RESULTS

Of 115 patients enrolled, 104 met the primary endpoint and were included in the analysis. No significant differences were noted in patient demographic, clinical, or operative characteristics. No differences were noted in median USSQ pain indices. The CNSL group used a significantly lower median number of A-OXY pills compared to the NARC group (2.4 vs. 5.4, p = 0.001) and less IBU compared to the NSAID group (3.1 vs. 5.9, p = 0.008). No differences in median total pill count, office calls, medication requests, nor ED visits were noted.

CONCLUSION

Our data suggest that patients can achieve equivalent postoperative analgesic satisfaction with non-narcotics compared to opiates following URS. Further, counseling patients on postoperative pain before surgery can reduce the total number of postoperative narcotic and non-narcotic medications taken. We suggest surgeons strongly consider omission of narcotic prescriptions following non-complicated URS.

Opioid-Limiting Pain Control After Transurethral Resection of the Prostate: A Randomized Controlled Trial

OBJECTIVE

To assess whether a multimodal opioid-limiting protocol and patient education intervention can reduce postoperative opioid use following transurethral resection of the prostate.

METHODS

This prospective, non-blinded, single-institution, randomized controlled trial (NCT04102566) assigned 50 patients undergoing a transurethral resection of the prostate to either a standard of care control (SOC) or multimodal experimental group (MMG). The intervention included adding ibuprofen to the postoperative pain regimen, promoting appropriate opioid use while hospitalized, an educational intervention, and discharging without opioid prescription. Data regarding demographics, operative data, opioid use, pain scores, and patient satisfaction were compared.

RESULTS

A total of 47 patients were included, n = 23 (MMG) and n = 24 (SOC). Demographic and operative findings were similar. Statistical analysis for noninferiority demonstrated non-inferior inpatient pain control (mean pain score 2.5 MMG vs 2.4 SOC, P = 0.0003). The multimodal group used significantly fewer morphine milligram equivalents after discharge (0 vs 4.1, P = 0.04). Inpatient use was reduced but did not reach statistical significance (6.0 vs 9.8, P = 0.2). Mean satisfaction scores with pain control were similar (9.6 MMG vs 9.2 SOC, P = 0.32). No opioid prescriptions were requested after discharge. Adverse events and medication side effects were infrequent and largely similar between groups.

CONCLUSION

Implementation of an opioid-limiting postoperative pain protocol and patient education resulted in no outpatient opioid use while maintaining patient satisfaction with pain control. Eliminating opioids following a common urologic procedure will decrease risk of opioid-related adverse events and have a positive downstream impact.

Toradol to Reduce Ureteroscopy Symptoms Trial (TRUST)

OBJECTIVE

To assess the use of intraoperative IV ketorolac (Toradol) on the peri-operative total morphine milligram equivalent (MME) requirements of patients undergoing ureteroscopy for nephrolithiasis.

METHODS

Patients undergoing ambulatory ureteroscopy for nephrolithiasis were randomized to receive ketorolac at time of anesthesia induction. Patients and surgeons were blinded to treatment. Intraoperative, postoperative and combined MME were calculated. Multivariable regression was used to identify independent predictors of MME requirement. Complications were recorded.

RESULTS

A total of 94 patients were analyzed following randomization. There were 46 patients in the treatment arm and 48 patients in the control arm. There were no statistically significant differences in gender, age, BMI, operative length or baseline pain medication use between groups (P >.05). Patients in the treatment arm required lower intraoperative MME when compared to the control arm (17.1 vs 24, P< .01). There were no statistically significant differences in the postoperative MME requirements between groups. The combined peri-operative MME was lower in the treatment arm compared to the control arm (22.2 vs 30.4, P< .02). Ketorolac use was an independent predictor of lower MME use on multivariable analysis (beta coefficient -5.1, P< .01). There was no statistically significant difference with regards to complication numbers between the treatment arms.

CONCLUSION

Ketorolac during ureteroscopy is associated with a 37% reduction in narcotic requirement and is an independent predictor of decreased peri-operative narcotic needs. These findings show that intra-operative use of ketorolac effectively reduces narcotic requirements and should be considered independently or as part of a multimodal pain control protocol, unless otherwise contraindicated.

Standardizing perioperative medications to be used in an enhanced recovered after surgery (ERAS) program is feasible in percutaneous nephrolithotomy patients

INTRODUCTION

The objective of this process improvement project was to determine the effect of enhanced recovery after surgery (ERAS) protocol for percutaneous nephrolithotomy (PCNL) patients with respect to quality of life and pain management in the post-operative recovery period.

METHODS

An electronic-based medical record ERAS orders protocol for PCNL was instituted at an academic medical center in July of 2020. The protocol utilized a pain control regimen designed to minimize opioid medication use post-operatively. We prospectively evaluated PCNL patients' quality of life via the Wisconsin Stone Quality of Life survey (WISQOL) and Patient-Reported Outcomes Measurement System (PROMIS) at routine perioperative visits. To assess any opioid reduction benefit of the ERAS protocol, we reviewed an age-matched historical cohort n = 66 (prior to ERAS implementation) to serve as a comparison cohort with respect to opioid usage.

RESULTS

After an inception cohort of 95 patients, 55 ERAS patients remained available for assessment with the WISQOL and PROMIS surveys. In comparison to the non-ERAS cohort, the ERAS cohort represented larger stones, more supine positioning, higher blood loss, shorter hospital stay and more use of access sheath. ERAS patients received a significantly lower amount of opioids compared to non-ERAS patients upon discharge narcotic usage (116.13 morphine milliequivalent (MME) vs. 39.57 MME, p=0.0001). Compared to their pre-operative evaluation, the ERAS cohort had significantly improved quality of life scores at 1 week which sustained through 8 weeks post-operatively. Moreover, pain intensity and pain interference scores were improved at 8 weeks post-operatively for ERAS patients compared to their pre-operative time point.

CONCLUSIONS

We demonstrate that standardizing medications in early efforts towards a PCNL ERAS protocol is feasible and allows for reduced opioid use by patients while achieving early and sustained post-procedure quality of life.

Opioid-Free Discharge is Not Associated With Increased Unplanned Healthcare Encounters After Ureteroscopy: Results From a Statewide Quality Improvement Collaborative

OBJECTIVES

To evaluate patient factors associated with post-ureteroscopy opioid prescriptions, provider-level variation in opioid prescribing, and the relationship between opioid-free discharges and ED visits.

METHODS

This is a retrospective analysis of a prospective cohort study of adults age 18 years and older who underwent primary ureteroscopy for urinary stones from June 2016 to September 2019 within the Michigan Urological Surgery Improvement Collaborative (MUSIC) Reducing Operative Complications from Kidney Stones (ROCKS) quality improvement initiative. Postoperative opioid prescription trends and variation among practices and surgeons were examined. Multivariable logistic regression models defined risk factors for receipt of opioid prescriptions. The association among opioid prescriptions and postoperative ED visits within 30 days of surgery was assessed among complete case and propensity matched cohorts, matched on all measured characteristics other than opioid receipt.

RESULTS

13,143 patients underwent ureteroscopy with 157 urologists across 28 practices. Post-ureteroscopy opioid prescriptions and ED visits declined (86% to 39%, P<.001; 10% to 6%, P<.001, respectively). Practice and surgeon-level opioid prescribing varied from 8% to 98%, and 0% to 98%, respectively. Patient-related factors associated with opioid receipt included male, younger age, and history of chronic pain. Procedure-related factors associated with opioid receipt included pre- and post-ureteroscopy ureteral stenting and access sheath use. An opioid-free discharge was not associated with increased odds of an ED visit (OR 0.77, 95% CI 0.62-0.95, P=.014).

CONCLUSIONS

There was no increase in ED utilization among those not prescribed an opioid after ureteroscopy, suggesting their routine use may not be necessary in this setting.

Pediatric Urologic Surgery: Reducing Opioid Use

Adequate pain management is important for successful postoperative recovery after any surgical procedure. Unfortunately, the USA and many other parts of the world are in the midst of an opioid epidemic, and healthcare providers are thus tasked with balancing the comfort and recovery of their patients after an operation against the individual and societal harms of the over-prescription of opioids. The goal of this article is to discuss the range of opioid formulations currently in use, examine why this may be problematic, and explore alternatives that provide similar efficacy and may improve overall safety in the pediatric population after urologic surgery. Improving the way opioids are prescribed through clinical practice guidelines as well as considering alternatives to opioids can ensure patients have access to safer and more effective pain treatments and potentially reduce opioid misuse.

Postoperative opioid-free ureteroscopy discharge: A quality initiative pilot protocol

BACKGROUND

Opioids are commonly prescribed after ureteroscopy. With an increasing adoption of ureteroscopy for management of urolithiasis, this subset of patients is at high risk for opioid dependence. We sought to pilot an opioid-free discharge protocol for patients undergoing ureteroscopy for urolithiasis.

MATERIALS AND METHODS

A prospective cohort study was performed of all patients undergoing ureteroscopy for urolithiasis and compared them to a historical control group. An opioid-free discharge protocol was initiated targeting all areas of surgical care from June 20th, 2019 to September 20th, 2019 as part of an institutional quality improvement initiative. Demographic and surgical data were collected as were morphine equivalent doses (MEDs) prescribed at discharge, postoperative measures including phone calls, clinic visits, and emergency room visits for pain.

RESULTS

Between October 1st, 2017 and February 1st, 2018, a total of 54 patients who underwent ureteroscopy were identified and comprised the historical control cohort while 54 prospective patients met the inclusion criteria since institution of the quality improvement initiative. There were no statistically significant differences in baseline patient demographics or surgical characteristics between the 2 patient groups. Total 37% of the intervention group had a preexisting opioid prescription versus 42.6% of the control group with no difference in preoperative MED (p = 0.55). The intervention group had a mean MED of 12.03 at discharge versus 110.5 in the control cohort (p ≤ 0.001). At discharge 3.7% of the intervention group received an opioid prescription versus 88.9% of the control group (p < 0.001). Overall, there was no difference in postoperative pain related phone calls (p = 1.0) or emergency room visits (p = 1.0).

CONCLUSIONS

An opioid-free discharge protocol can dramatically reduce opioid prescription at discharge following ureteroscopy for urinary calculi without affecting postoperative measures such as phone calls, clinic visits, or subsequent prescriptions.

Evidence-Based Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery

INTRODUCTION

Procedure-specific guidelines for postsurgical opioid use can decrease overprescribing and facilitate opioid stewardship. Initial recommendations were based on feasibility data from limited pilot studies. This study aims to refine opioid prescribing recommendations for endourological and minimally invasive urological procedures by integrating emerging clinical evidence with a panel consensus.

METHODS

A multistakeholder panel was convened with broad subspecialty expertise. Primary literature on opioid prescribing after 16 urological procedures was systematically assessed. Using a modified Delphi technique, the panel reviewed and revised procedure-specific recommendations and opioid stewardship strategies based on additional evidence. All recommendations were developed for opioid-naïve adult patients after uncomplicated procedures.

RESULTS

Seven relevant studies on postsurgical opioid prescribing were identified: four studies on ureteroscopy, two studies on robotic prostatectomy including a combined study on robotic nephrectomy, and one study on transurethral prostate surgery. The panel affirmed prescribing ranges to allow tailoring quantities to anticipated need. The panel noted that zero opioid tablets would be potentially appropriate for all procedures. Following evidence review, the panel reduced the maximum recommended quantities for 11 of the 16 procedures; the other 5 procedures were unchanged. Opioids were no longer recommended following diagnostic endoscopy and transurethral resection procedures. Finally, data on prescribing decisions supported expanded stewardship strategies for first-time prescribing and ongoing quality improvement.

CONCLUSION

Reductions in initial opioid prescribing recommendations are supported by evidence for most endourological and minimally invasive urological procedures. Shared decision-making prior to prescribing and periodic reevaluation of individual prescribing patterns are strongly recommended to strengthen opioid stewardship.

Long-term Success With Diminished Opioid Prescribing After Implementation of Standardized Postoperative Opioid Prescribing Guidelines: An Interrupted Time Series Analysis

OBJECTIVE

To assess longitudinal prescribing patterns for patients undergoing urologic surgery in the nearly 2-year time frame before and after implementation of an evidence-based opioid prescribing guideline to accurately characterize the impact on postoperative departmental practices.

PATIENTS AND METHODS

Historical prescribing data for adults who underwent 21 urologic procedures at 3 academic institutions were used to derive a 4-tiered guideline for postoperative opioid prescribing. The guideline was implemented on January 16, 2018, and prescribing patterns including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid-naïve patients undergoing urologic surgery before (January 1, 2016, through January 15, 2018; N=10,649) and after (January 16, 2018, through September 30, 2019; N=9422) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and χ² tests. Cochran-Armitage trend tests and interrupted time series analysis were used to test for significance in the change in OMEs prescribed before vs after guideline implementation.

RESULTS

The median quantity of opioids decreased from 150 OMEs (interquartile range, 0-225) before guideline implementation to 0 OMEs (interquartile range, 0-90) after guideline implementation (P<.001). Median OMEs decreased significantly in each tier and each of 21 individual procedures. Overall guideline adherence was 90.7% (n=8547). Despite this decrease in OMEs prescribed, post-guideline implementation patients obtained fewer refills than the pre-guideline implementation group (614 [6.5%] vs 999 [9.4%]; P<.001).

CONCLUSION

In a multi-institutional follow-up prospective study of adult urologic surgery-specific evidence-based guidelines for postoperative prescribing, we demonstrate sustained reduction in OMEs prescribed secondary to guideline implementation and adherence by our providers.

Opioid Use after Pediatric Urologic Surgery: Is It Really Needed?

OBJECTIVES

To identify factors associated with opioid use after pediatric urologic surgery, use this data to educate our patients and colleagues on decreasing post-operative opioid use, and assess the effectiveness of this approach.

METHODS

From 1/2018 - 12/2019, a written questionnaire asking which pain medications were used after surgery was given to patients' families before routine post-operative appointments. A retrospective review of the surveys and patient charts was performed. Demographic factors were compared between patients who did and did not use opioids with Fisher's exact and t tests. Midway through the study, the results were presented to the urology department in an attempt to reduce opioid use over the next year. The number of opioid prescriptions and patients who used opioids after surgery in 2018 versus 2019 was compared.

RESULTS

1001 patients were included with a mean age of 5 years, 96% male. Patients used a mean of 4.5 doses of opioids and 83% had leftover opioids. Factors significantly associated with not using opioids included age less than 3, penile, and endoscopic surgery. Between 2018 and 2019-despite no significant difference in patient age, gender, or procedure type-the number of patients who were prescribed (61% vs 34%, P < .0001) and who used opioids (55 vs 28%, P < .0001) was significantly decreased.

CONCLUSION

After pediatric urologic surgery, many patients do not need opioid prescriptions. Reviewing our own opioid use practices and providing education within our department allowed us to significantly decrease the number of opioids prescribed and used after surgery.

Opioid Free Ureteroscopy: What is the True Failure Rate?

OBJECTIVE

To determine the true failure rate of opioid free ureteroscopy (OF-URS) and rates of new-persistent opioid use utilizing a national prescription drug monitoring program.

MATERIAL AND METHODS

We identified 239 patients utilizing our retrospective stone database who underwent OF-URS from Februrary 2018-March 2020. In Feb 2018, we initiated a OF-URS pathway (diclofenac, tamsulosin, acetaminophen, pyridium and oxybutynin). Patients who had a contraindication to NSAIDs were excluded from primary analyses. A prescription drug monitoring program was then utilized to determine the number of patients who failed OF-URS (defined as receipt of an opioid within 31 days of surgery) as well as rates of new-persistent opioid use (defined as receipt of opioid 91-180 days after surgery). All statistical analyses were performed using SAS 9.4. Tests were 2-sided and statistical significance was set at P<0.05.

RESULTS

We found a OF-URS failure rate of 16.6% and 14.0% in the total and opioid naïve cohorts, respectively. Rates of new-persistent opioid use were 0.9% and 1.2%, respectively (lower than published expected rate of ~6% after URS with postoperative opioids). 91% of patients obtained opioid from alternative sources. Uni/multivariate analyses were performed for both cohorts. In the total cohort, benzodiazepine users had a lower risk of OF-URS failure on multivariate analysis. No variables were associated with OF-URS failure in the opioid naïve cohort.

CONCLUSION

The true failure rate of OF-URS is higher than previously thought at 16.6% and 14.0%. However, efforts to reduce opioid prescriptions with OF-URS pathways have successfully reduced new-persistent opioid use.

Patterns of opioid prescription post ureteroscopy among members of the Endourological Society

Background

Postoperative opioid prescribing has been linked with persistent opioid use. Ureteroscopy (URS) is a common urologic procedure and a potential area to focus on opioid reduction. We aim to characterize international practice patterns of opioid prescribing post URS and what measures may decrease the need for opioid prescription.

Methods

We developed a survey directed to members of the Endourological Society. The survey queried the frequency of opioid prescribing post URS, challenges when opioids are not prescribed, and measures thought to reduce the need for opioids.

Results

We received 159 responses with the majority reported practicing urology for >20 years (37.1%), and performing 10–20 ureteroscopies/month (45.3%). Forty-one percent were from the United States (US) and Canada. Sixty-six percent completed a fellowship, 84% in endourology. Twenty-six percent prescribe opioids more than half the time and the majority do so less than 10% of the time (61.6%). Thirty-eight percent had no challenges when opioids were omitted. Measures felt to decrease the need for opioids were preoperative counseling, nonsteroidal anti-inflammatory drugs use, and use of adjunct medications. After adjusting for location and type of practice, endourology fellowship completion, years of practice, and number of ureteroscopies/month, we found that respondents from the US and Canada were more likely to prescribe opioids more than half the time post URS compared to respondents from the rest of the world [odds ratio (OR): 87.5, P<0.001, 95% confidence interval (CI): 17.3–443.5].

Conclusions

Despite proven feasibility of non-opioid pathway, nearly one-quarter of participants in our survey prescribe opioids >50% of the time post URS. Most important factors felt to reduce opioid prescription post URS were preoperative counseling, nonsteroidal anti-inflammatory drugs use. US and Canadian urologists were more likely to prescribe opioids >50% of the time post URS compared to the rest of the world. We believe best practice guidelines should be considered by the American and Canadian Urological Associations to address post URS opioid prescribing.

Opioids and Kidney Stones

In recent years, the use of opioids in medical practice has come under significant scrutiny. This, in part, is owing to evidence of overprescription and overuse of opioid medications, as well as the unintended consequences and side effects for patients who take these medications. Here, we review the role of opioids and the responsible use of these medications with respect to kidney stone disease and surgical interventions for kidney stones.

Is spinal anesthesia an alternative and feasible method for proximal ureteral stone treatment?

Introduction

We investigated the clinical, operational, and pain parameters of patients who underwent semirigid ureterorenoscopy (sURS) under spinal anesthesia (SA) and general anesthesia (GA) for proximal ureter stones.

Material and methods

Patients treated with sURS after diagnosis of proximal ureter stones between January 2014 and May 2017 were reviewed retrospectively. The patients were divided into two groups (the SA group and the GA group) based on the type of anesthesia used. Perioperative variables and operation results were evaluated and compared. Success was defined as the patient being stone-free as observed on low-dose non-contrast computed tomography performed in the first month postoperatively.

Results

The SA and GA groups had 40 and 32 patients, respectively. There were no statistically significant differences between the groups in terms of age (p = 0.593), gender (p = 0.910), average stone size (p = 0.056), side (p = 0.958), or density (p = 0.337). Based on the Clavien classification system, complication rates between the two groups were similar. The postoperative visual pain scale in the SA group was statistically significantly lower (p <0.05) than in the GA group. Success rates in the SA and GA groups were found to be 90% (36/40) and 93.7% (30/32), respectively, with no significant difference between the groups (p = 0.819).

Conclusions

Ureterorenoscopy, which is performed for proximal ureter stone treatment in adult patients, is a reliable surgical method that can be performed under both SA and GA. SA offers the advantage of reduced postoperative pain as compared to GA.

A Longitudinal Cohort Study of Pain Intensity and Interference After Ureteroscopy for Nephrolithiasis Without Postoperative Opioids

OBJECTIVE

To better understand the degree and time to resolution of pain in the postoperative period, we captured patient-reported pain intensity and interference prospectively in patients following ureteroscopy for nephrolithiasis.

MATERIALS AND METHODS

Adults undergoing ureteroscopy for renal/ureteral stones from 11/2018 to 1/2020 were eligible for inclusion. All received nonopioid postoperative pain control. Patients prospectively completed Patient-Reported Outcome Measurement Information System-Pain Intensity and Patient-Reported Outcome Measurement Information System-Pain Interference instruments preoperatively on postoperative day (POD) 0 and via email on POD 1, 7, and 14. Scores are reported as T-scores (normalized to US population, mean = 50) with changes of 5 (0.5 standard deviation) considered clinically significant.

RESULTS

A total of 126 patients completed enrollment at POD 0 (POD 1 = 74, POD 7 = 61, POD 14 = 47). Compared to US means, intensity and interference were significantly different at all time point comparisons (Wilcoxon rank test; all P <.001) except intensity at POD 7 (P = .09) and interference at POD 14 (P = .12). For both, there was a significant difference at each time comparison (repeated measures ANOVA; all P <.05). Increasing age was predictive of lower intensity (Confidence Interval (CI): -0.31 to -0.04; P = .012) and interference (CI: -0.36 to -0.06; P =.01) at POD 1. The presence of a postoperative stent was predictive of higher intensity (CI: 0.68-10.81; P = .03) and interference (CI: 0.61-12.96; P = .03) at POD 7. Increasing age remained a predictor of lower interference at POD 1 on multivariable analysis (CI: -0.46 to -0.01; P = .03).

CONCLUSION

Pain intensity and interference are elevated immediately, but intensity normalizes by POD 7, while interference remains elevated until POD 14. Age and indwelling ureteral stent influence both intensity and interference.

Early Surgical Intervention for Symptomatic Renal and Ureteral Stones is Associated With Reduced Narcotic Requirement Relative to Trial of Passage

OBJECTIVES

To evaluate if trial of passage (TOP) or initial surgical intervention resulted in less narcotic analgesia utilization in patients with acute renal colic due to stone disease.

METHODS

We retrospectively evaluated 135 patients with acute renal colic due to nephroureterolithiasis managed by a single surgeon. Patients were standardly offered TOP or surgical intervention with ureteroscopy (URS). A subset of patients were stented with delayed URS due to presence of infection, pain, or a nonaccommodating ureter. Our standard practice is narcotic-free URS, prescribing a stent cocktail including non-steroidal anti-inflammatories. We compared rates of narcotic prescription over the entire treatment course for patients electing TOP vs surgery (primary or delayed URS). We secondarily analyzed rates of surgical intervention among initial TOP.

RESULTS

We included 135 patients, with 69 (51.1%) TOP as initial treatment, 39 (28.9%) stent with delayed URS, and 27 (20.0%) primary URS. Thirty-nine (56.5%) TOP patients underwent URS at a median time of 18 days (IQR 6-31 days) from diagnosis. More TOP patients required a narcotic prescription (60.9% vs 35.9% vs 33.3%, respectively; P = .010) compared to patients undergoing initial stent or URS. However, when an opioid prescription was provided, the total morphine milligram equivalents prescribed among each group was not statistically significant.

CONCLUSION

Patients electing initial treatment with TOP for renal colic due to stone disease were more likely to require narcotic prescriptions than patients electing initial surgical intervention.

Opiates prescribed for acute renal colic are associated with prolonged use

PURPOSE

Patients presenting with acute renal colic may be at risk of opiate abuse. We sought to analyze prescribing patterns and identify risk factors associated with prolonged opiate use during episodes of acute renal colic.

METHODS

Retrospective study of patients presenting with both a stone confirmed on imaging and an acute pain episode from 6/2017-2/2020. Opiate prescription data was obtained from a statewide prescribing database. Primary outcome was an opiate refill or new opiate prescription prior to resolution of the stone episode (either passage or surgery). Univariate and multivariate linear regression analysis was performed.

RESULTS

A total of 271 patients met inclusion criteria. Mean age was 52 years and 48% had a history of nephrolithiasis. 180 (66%) patients filled a new opiate prescription during their acute stone episode. Thirty-eight (14%) patients had an existing opiate prescription within 3 months of their stone episode. Seventy-four (27%) patients refilled an opiate prescription prior to stone passage or surgery. Larger stone size, need for surgery, prolonged time to treatment, existing opiate prescription, new opiate prescription at presentation, and greater initial number of pills prescribed were associated with increased risk of requiring a refill prior to stone resolution.

CONCLUSIONS

Patients prescribed new opiates for acute nephrolithiasis and those with an existing opioid prescription are likely to require refills before resolution of the stone episode. Larger stones that require surgery (not spontaneous passage) also increase the risk. Timely treatment of these patients and initial treatment with non-narcotics may reduce the risk of prolonged opiate use.

Decreasing postoperative opioid use while managing pain: A prospective study of men who underwent scrotal surgery

Objective

To compare postoperative pain control among men who received different quantities of narcotic prescriptions following scrotal surgery. We hypothesized that men receiving eight vs four pills of acetaminophen 300 mg/codeine 30 mg there would be no significant difference in mean pain following scrotal and inguinal surgery.

Patients and methods

In this prospective, open‐label study, men who underwent scrotal surgery received eight or four acetaminophen 300 mg/codeine 30 mg pills. Men were encouraged to take scheduled non‐steroidal anti‐inflammatory drugs (NSAIDs), apply ice on the incision, and take acetaminophen 300 mg/codeine 30 mg as needed for breakthrough pain. Men were evaluated within 1‐2 weeks after surgery. Statistical analysis was performed using Microsoft Excel and Stata/IC 15.1.

Results

A total of eighty‐seven men met inclusion criteria, fifty‐four men received eight acetaminophen/codeine pills, and thirty‐three men received four pills. There was no significant difference in mean pain score (0‐10) of men receiving eight pills vs four pills in the week after surgery (3.6 ± 1.9 vs 3.3 ± 1.8, P = .5004). Of men who used NSAIDs and ice, 93.5% and 92.3% found them to be moderately or very helpful.

Conclusion

Reducing the total prescription of combined narcotic/non‐narcotic medication is not associated with increased postoperative pain in patients undergoing scrotal/inguinal surgery. There was no difference in postoperative pain in men taking eight or four acetaminophen 300 mg/codeine 30 mg pills. A limited prescription of eight or four pills was adequate for pain control in the majority of men who underwent scrotal surgery. NSAIDs and ice were found to be useful adjuncts for pain relief by those who used them.

Enhanced Recovery After Surgery Protocol for Patients Undergoing Ureteroscopy: Prospective Evaluation of an Opioid-Free Protocol

Purpose: A large part of the national opioid epidemic has been tied to prescription opioids, leading to a push to reduce or eliminate their use when feasible. The objective of this study was to evaluate outcomes of implementing an Enhanced Recovery After Surgery (ERAS) protocol for patients undergoing ureteroscopic stone treatment with stent placement geared toward minimizing opioid use. Materials and Methods: We performed a pre-post study concerning a process improvement project of consecutive patients undergoing ureteroscopic stone treatment with stent placement utilizing a novel ERAS protocol. A lead-in period with patients managed conventionally with opioids was performed before implementation of the ERAS protocol. Data regarding opioid utilization, postoperative outcomes, and patient-reported outcomes, including Patient-Reported Outcomes Measurement Information System (PROMIS), were compared between groups. Results: There were 28 pre-ERAS patients and 52 ERAS-managed patients. Patients discharged with an opioid prescription decreased from 93% to 0% (p < 0.05). Mean total morphine milligram equivalent decreased from 60.1 ± 41 to 7.7 ± 26 (p < 0.05). There was no significant difference noted for postoperative calls for pain in the pre-ERAS vs ERAS groups (25% vs 19%, p = 0.9) or in unscheduled provider encounters (0% vs 4%, p = 0.46). There were no clinically significant differences between groups on patient-reported measures. Conclusions: Implementation of an ERAS protocol for ureteroscopic stone treatment resulted in a significant reduction in perioperative opioids, a total reduction in discharge opioid prescriptions, and ∼90% reduction in total 30-day postoperative opioid prescribing with no adverse effects on recovery or increase in postoperative clinical encounters.

Kidney stones and the opioid epidemic: recent developments and review of the literature

PURPOSE OF REVIEW

A public health emergency has been declared in response to rising opioid addiction and opioid-related deaths in the United States. As kidney stones have been identified as an important source of initial and repeated opioid exposures, this review seeks to describe the scope of the problem and report relevant alternatives to opioid analgesia for stones.

RECENT FINDINGS

Recent literature summarizing the extent of opioid use among those with stones is reviewed. A number of opioid-minimizing strategies and analgesic regimens have been proposed and studied. A review of these modifications and alternatives is provided.

SUMMARY

Both symptomatic renal colic and surgical interventions to address stones may prompt need for analgesia. Reducing prescribed opioids reduces both patient use and risk of diversion. Modifications in surgical technique, administration of local anesthetics, and use of systemic nonopioid analgesics have all been successfully employed.

New Persistent Opioid Use After Outpatient Ureteroscopy for Upper Tract Stone Treatment

OBJECTIVE

To measure the incidence of persistent opioid use following ureteroscopy (URS). Over 100 Americans die every day from opioid overdose. Recent studies suggest that many opioid addictions surface after surgery.

METHODS

Using claims data, we identified adults who underwent outpatient URS for treatment of upper tract stones between January 2008 and December 2016 and filled an opioid prescription attributable to URS. We then measured the rate of new persistent opioid use-defined as continued use of opioids 91-180 days after URS among those who were previously opioid-naive. Finally, we fit multivariable models to assess whether new persistent opioid use was associated with the amount of opioid prescribed at the time of URS.

RESULTS

In total, 27,740 patients underwent outpatient URS, 51.2% of whom were opioid-naïve. Nearly 1 in 16 (6.2%) opioid-naïve patients developed new persistent opioid use after URS. Six months following surgery, beneficiaries with new persistent opioid use continued to fill prescriptions with daily doses of 4.2 oral morphine equivalents. Adjusting for measured sociodemographic and clinical differences, patients in the highest tercile of opioids prescribed at the time of URS had 69% higher odds of new persistent opioid use compared to those in the lowest tercile (odds ratio, 1.69; 95% CI, 1.41-2.03).

CONCLUSION

Nearly 1 in 16 opioid-naive patients develop new persistent opioid use after URS. New persistent opioid use is associated with the amount of opioid prescribed at the time of URS. Given these findings, urologists should re-evaluate their post-URS opioid prescribing patterns.

Opiate Exposure and Predictors of Increased Opiate Use After Ureteroscopy

Objective: Kidney stone formers are at risk for opioid dependence. The aim of this study is to describe opiate exposure and determine predictors of prolonged opiate use among kidney stone formers after surgery. Materials and Methods: A retrospective review was performed among patients who underwent ureteroscopy for upper tract stone disease. Prescription data were ascertained from a statewide prescribing database. Demographic data and surgical factors were collected from the electronic medical record. Predictors of additional postsurgery prescriptions filled within 30 days and persistent opiate use 60 days after ureteroscopy were determined. Results: Among 208 patients, 127 (61%) had received preoperative opiate prescriptions within 30 days before surgery. Overall, 12% (n = 25) of patients required an additional opiate prescription within 30 days after ureteroscopy, and 7% (n = 14) of patients continued to use opiate medications more than 60 days postoperatively. Patients continuing to use opiates long-term were not chronic opiate users. For both outcomes, preoperative opiate exposure, including number of prescriptions, days prescribed, and unique providers had significant associations (all p < 0.05). Additionally, younger age (p = 0.049) was associated with obtaining an additional opiate prescription within 30 days. Lower BMI (p = 0.02) and higher ASA score (p = 0.03) were predictors of continued opiate use more than 60 days after ureteroscopy. Conclusions: The majority of stone formers have had opiate exposure before surgery, often from multiple providers. Approximately 1 in 8 stone formers who undergo ureteroscopy require additional opiate prescriptions within 30 days. A small but significant population receive opiates beyond the immediate postoperative period.