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Lee JE, Oh J, Lee JN, Ri HS, Lee CS, Yeo J. Comparison of a Non-Opioid Multimodal Analgesia Protocol with Opioid-Based Patient-Controlled Analgesia for Pain Control Following Robot-Assisted Radical Prostatectomy: A Randomized, Non-Inferiority Trial. J Pain Res 2023; 16:563-572. [PMID: 36846203 PMCID: PMC9946841 DOI: 10.2147/jpr.s397529] [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: 11/14/2022] [Accepted: 02/01/2023] [Indexed: 02/19/2023] Open
Abstract
Background Opioid use after surgery is a potential contributor to the opioid epidemic. An adequate pain control method after surgery while minimizing opioid exposure is needed. This study aimed to compare the effect of non-opioid multimodal analgesia (NOMA) protocol with opioid-based patient-controlled analgesia (PCA) for pain relief after robot-assisted radical prostatectomy (RARP). Methods This prospective randomized, open, non-inferiority trial included 80 patients scheduled for RARP. The NOMA group received pregabalin, paracetamol, bilateral quadratus lumborum block, and pudendal nerve block. PCA group received PCA. Pain scores, postoperative nausea and vomiting, opioid requirements, and quality of recovery were recorded 48 hours after surgery. Results We found no significant differences in pain scores. The mean difference in pain score during rest at 24 h was 0.5 (95% CI -0.5 to 2.0). This result demonstrated the non-inferiority of NOMA protocol to PCA at our non-inferiority margin (-1). In addition, 23 patients in the NOMA group did not receive any opioid agonist for 48 h after surgery. Recovery of bowel function was also faster in the NOMA group than in the PCA group (25.0 hours vs 33.4 hours, p = 0.01). Limitations We did not evaluate whether our NOMA protocol could decrease the incidence of new continuous opioid use after surgery. Conclusion NOMA protocol successfully controlled postoperative pain and was non-inferior to morphine-based PCA regarding patient-reported pain intensity. It also promoted recovery of bowel function and decreased postoperative nausea and vomiting.
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Affiliation(s)
- Jeong Eun Lee
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Jinyoung Oh
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Jun Nyung Lee
- Department of Urology, School of Medicine, Kyungpook National University, Kyungpook National University Chilgok Hospital, Daegu, Korea
| | - Hyun-Su Ri
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Chang Sub Lee
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Kyungpook National University Hospital, Daegu, Korea
| | - Jinseok Yeo
- Department of Anesthesiology and Pain Medicine, Kyungpook National University School of Medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea,Correspondence: Jinseok Yeo, Department of Anesthesiology and Pain Medicine Kyungpook National University School of medicine, Kyungpook National University Chilgok Hospital, Daegu, Korea, Tel +82-53-200-2644, Fax +82-53-200-2027, Email
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Demus T, Lopategui DM, Vieweg J, Masel J, Bhandari A, Nieder AM. Variations in Opioid Use Following Robotic Radical Prostatectomy in South Florida. J Endourol 2022; 36:1532-1537. [PMID: 35856823 DOI: 10.1089/end.2022.0212] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Introduction: Opioid dependency has been a persistent issue in the United States over the past two decades. Increased efforts have been made to reduce opioid prescribing. Our objective was to quantify at-home opioid requirements following radical prostatectomy. Methods: Written questionnaires were administered to patients 1 week following robot-assisted laparoscopic radical prostatectomy (RALP). Patients provided data on opioid use, pain levels, and demographic characteristics. Results: Sixty-five patients were included. Median age (interquartile range [IQR]) was 69 (62-72) years. The majority were white (85%) and hispanic (67%). Prescriptions ranged from 6 to 15 pills of 5-mg oxycodone equivalents. Twenty-two percent (145/663) of the prescribed pills in the study were consumed. Fifty-four percent (35/65) of patients did not take opioids. Of the 30 patients who took opioids, median use (IQR) was 4.5 (3-6) pills. Forty-six percent (30/65) reported catheter-related pain. Patients who took opioids reported higher levels of pain. On generalized linear regression, younger age, lower levels of education, and living with a family member were factors associated with increased risk for opioid use (all p < 0.05). Conclusions: Despite the Florida Department of Health's restriction on narcotic prescriptions to 3-day supplies, opioids are still overprescribed in our region. The majority of patients do not require opioids after RALP, and patients who do require an opioid analgesic can be adequately managed with less than 6 pills of 5-mg oxycodone equivalents.
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Affiliation(s)
- Timothy Demus
- Department of Urology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Diana M Lopategui
- Department of Urology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Johannes Vieweg
- Department of Surgery, Dr. Kiran C. Patel College of Allopathic Medicine, Nova Southeastern University, Fort Lauderdale, Florida, USA
| | - Jonathan Masel
- Department of Urology, Memorial Healthcare System, Hollywood, Florida, USA
| | - Akshay Bhandari
- Department of Urology, Mount Sinai Medical Center, Miami Beach, Florida, USA
| | - Alan M Nieder
- Department of Urology, Mount Sinai Medical Center, Miami Beach, Florida, 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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4
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Mishra K, Jesse E, Bukavina L, Sopko E, Arojo I, Fernstrum A, Ray A, Mahran A, Calaway A, Block S, Ponsky L. Impact of Music on Postoperative Pain, Anxiety, and Narcotic Use After Robotic Prostatectomy: A Randomized Controlled Trial. J Adv Pract Oncol 2022; 13:121-126. [PMID: 35369398 PMCID: PMC8955566 DOI: 10.6004/jadpro.2022.13.2.3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Background Music is a safe and cost-effective intervention that can reduce postoperative pain and anxiety. We investigated the effects of music therapy on postoperative recovery in patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). Methods Subjects were males 18 years and older undergoing RALP at a single tertiary care institution. Patients were randomized to music or control groups. The music group received 30 minutes of music in the recovery area and on postoperative day (POD) 1, while the control group was not provided postoperative music. Inpatient narcotic use (morphine milligram equivalent, or MME) and outpatient narcotic use were measured, and the State-Trait Anxiety Inventory (STAI) survey was completed on POD 1 and POD 7 by an inpatient advanced practitioner (AP). T-test and Chi-square were used to compare the groups. Linear regression was used to adjust for age, blood loss, and inpatient MME. Results A total of 40 patients were prospectively recruited. There was no statistically significant difference in the hourly MME (2.06 [0.71-3.17] vs. 1.55 [0.83-3.37]) or total MME (49.52 [17-76] vs. 37.25 [20-69]) used in the music vs. non-music arms, respectively. Evaluation of STAI questionnaire revealed no overall differences in anxiety levels among the two groups on POD 1 or POD 7. After adjusting for age, blood loss, and inpatient MME use, patients assigned to the music intervention had a 26% reduction in post-hospitalization use. Conclusion Our prospective randomized study suggests that music can be an AP-driven adjunct to facilitate postoperative patient comfort and reduce narcotic use upon discharge in prostate cancer patients.
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Affiliation(s)
- Kirtishri Mishra
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Erin Jesse
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Laura Bukavina
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Emily Sopko
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
| | - Itunu Arojo
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Austin Fernstrum
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Al Ray
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Amr Mahran
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Adam Calaway
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
| | - Seneca Block
- University Hospitals Connor Integrative Health Network, Department of Music Therapy, Cleveland, Ohio
| | - Lee Ponsky
- From University Hospitals Cleveland Medical Center, Urology Institute, Cleveland, Ohio
- Case Western Reserve University School of Medicine, Cleveland, Ohio
- Case Comprehensive Cancer Center, Case Western Reserve University School of Medicine, Cleveland, Ohio
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5
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Abstract
Higher capital costs and operating room costs associated with Lobectomy via Robot Assisted Thoracic Surgery (RATS) have previously been suggested as the principal contributors to the elevated overall cost. This study uses a micro-costing approach to a previous analysis of clinical outcomes of RATS, Video-Assisted Thoracic Surgery (VATS) and Open Lobectomy to evaluate the most significant cost drivers for the higher cost of robot-assisted lobectomy. A micro-costing model was developed to reflect the pathway of patients from day of surgery through the first 30 days following lobectomy. Costs were provided for RATS, VATS and Open approaches. Sensitivity analysis was performed specifically in the area of staff costs. A threshold sensitivity analysis of the overall cost components was also performed. Total cost per case for the RATS approach was €13,321 for the VATS approach €11,567, and for the Open approach €12,582. The overall cost differences were driven primarily by the elevated consumable costs associated with RATS Lobectomy. Capital costs account for a relatively small proportion of the per-case cost difference. This study presents a detailed analysis of the cost drivers for lobectomy, modelled for the three primary surgical approaches. We believe this is a useful tool for surgeons, hospital management, and service commissioning agencies to accurately and comprehensively determine where cost savings can be applied in their programme to improve the cost-effectiveness of RATS lobectomy.
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6
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Harnessing choice architecture in urologic practice: Implementation of an opioid-sparing protocol grounded in cognitive behavioral theory. Urol Oncol 2021; 40:95-102. [PMID: 34876350 DOI: 10.1016/j.urolonc.2021.10.011] [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: 09/13/2021] [Accepted: 10/23/2021] [Indexed: 10/19/2022]
Abstract
PURPOSE Opioids are prescribed excessively following surgery. As many urologic oncology procedures are performed minimally invasively, an opportunity exists to push forward initiatives to minimize postoperative opioid use. MATERIALS AND METHODS A quality improvement initiative to reduce inpatient opioid prescribing was launched at a tertiary cancer center. In Phase I (December 2019-July 2020), providers were instructed to start standing acetaminophen. In Phase II (beginning August 2020), education was provided to the entire care team and ordersets were modified to an opioid sparing protocol (OSP). We analyzed the proportion of minimally invasive surgery (MIS) prostatectomy and nephrectomy patients that adhered to an OSP during each phase and compared them to controls from the preceding 2 years. RESULTS A total of 303, 153, and 839 patients underwent MIS during the Phase I, Phase II, and control periods respectively. The proportion of patients adhering to an OSP increased from 16% at the beginning of Phase I to 76% at the end of Phase II (p-trend < 0.001). The median total oral morphine equivalents for oral opioids declined from 20 mg and 40 mg at baseline for prostatectomy and nephrectomy patients respectively to 0 mg for both groups (p-trends < 0.001). Multivariable analysis found that patients received 22% and 81% less oral morphine equivalents during Phase I and II respectively compared to the control period (P < 0.001). CONCLUSIONS Adherence to an OSP is most effective when initiatives incorporate the entire team and are supported by nudge theory-based structural changes. Using these strategies, most patients following urologic MIS can dramatically reduce opioid use postoperatively.
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Puliatti S, Piazza P, Cacciamani GE, Gómez Rivas J, Taratkin M, Marenco JL, Rivero Belenchon I, Kowalewski KF, Checcucci E. Comment on: "Predictive factors for opioid-free management after robotic radical prostatectomy: the value of a single-port robotic platform". Minerva Urol Nephrol 2021; 73:677-679. [PMID: 34847651 DOI: 10.23736/s2724-6051.21.04724-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Affiliation(s)
- Stefano Puliatti
- Department of Urology, University of Modena and Reggio Emilia, Modena, Italy.,Orsi Academy, Ghent, Belgium
| | - Pietro Piazza
- Orsi Academy, Ghent, Belgium.,Department of Urology, S. Orsola-Malpighi University Hospital, Bologna, Italy
| | | | - Juan Gómez Rivas
- Department of Urology, Hospital Clínico San Carlos, Madrid, Spain
| | - Mark Taratkin
- Institute for Urology and Reproductive Health, Sechenov University, Moscow, Russia
| | - José L Marenco
- Department of Urology, Valencian Institute of Oncology Foundation, Valencia, Spain
| | - Ines Rivero Belenchon
- Department of Urology and Nephrology, Virgen del Rocío University Hospital, Seville, Spain
| | - Karl-Friedrich Kowalewski
- Department of Urology and Urological Surgery, Mannheim University Medical Center, Heidelberg University, Mannheim, Germany
| | - Enrico Checcucci
- Department of Oncology, School of Medicine, San Luigi Gonzaga Hospital, University of Turin, Orbassano, Turin, Italy - .,Department of Surgery, Candiolo Cancer Institute, FPO-IRCCS, Candiolo, Turin, Italy
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8
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[Interactions between radical prostatovesiculectomy and diagnosis of prostate cancer : A medical-historical inventory on the occasion of 20 years of robot-assisted treatment]. Urologe A 2021; 60:1039-1050. [PMID: 33201298 PMCID: PMC7670839 DOI: 10.1007/s00120-020-01389-1] [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] [Indexed: 11/30/2022]
Abstract
Die Frage, was zuerst war – in diesem Falle die Diagnostik des Prostatakarzinoms oder seine Therapie – erscheint auf den ersten Blick widersinnig und erinnert an die klassische metapherartige Problemstellung, die schon den griechischen Schriftsteller Plutarch (45–125) beschäftigte. Ist es heute selbstverständlich, dass vor der Behandlung einer Erkrankung die sichere Diagnosestellung steht, so muss dies medizinhistorisch jedoch als nicht konsistent erachtet werden. Die Anfänge der radikalen Prostatektomie zur Behandlung des Prostatakarzinoms lassen sich, ähnlich wie die ersten operativen Therapien von Nieren- und Harnblasentumoren, in der Pionierzeit der Organchirurgie im Deutschen Kaiserreich (1871–1918) verorten. Die Etablierung dieses Eingriffs in seiner heutigen Form mit größeren Fallzahlen ist wiederum dem Nestor der US-amerikanischen Urologie, Hugh Hampton Young (1870–1945), zu verdanken, der 1904 die erste aus heutiger Sicht als vollumfänglich zu bezeichnende perineale Prostatovesikulektomie durchführte. Wenngleich die Indikation seither weitgehend unverändert geblieben ist, war dieser Eingriff in den letzten Jahrzehnten doch umfangreichen Veränderungen unterworfen. Wie aber hat sich die Diagnostik des Prostatakarzinoms in dieser Zeitspanne entwickelt? Naturgemäß sehr viel dynamischer! Denn als der Leiteingriff Prostatovesikulektomie bereits etabliert war, begann im Laufe des 20. Jahrhunderts erst langsam, dann dynamischer deren Entwicklung. Wir stellen anhand medizin(histor)ischer Originalquellen daher nicht nur die Grundlagen und Weiterentwicklungen des etablierten und zugleich immer wieder Innovationen unterworfenen Leiteingriffs der Urologie vor, sondern gehen vielmehr auch auf wesentliche Umfeldentwicklungen benachbarter medizinischer Disziplinen ein. Erst diese Entwicklungen schafften übrigens auch die Grundlage für die korrekte Indikationsstellung und das Aufzeigen von Alternativen zur radikalen Prostatovesikulektomie.
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Tas S, Eren AE, Islamoğlu E, Polat S, Ateş M, Savaş M. Should Peritoneal Re-Approximation be Performed After Transperitoneal Robot-Assisted Radical Prostatectomy? J Laparoendosc Adv Surg Tech A 2021; 32:265-269. [PMID: 33661035 DOI: 10.1089/lap.2021.0046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Background: The aim of the study is to examine the effect of peritoneal re-approximation or non-approximation on the postoperative course of patients at the end of transperitoneal robot-assisted radical prostatectomy (tRARP).It is also aimed to examine the relationship between peritoneal re-approximation or non-approximation and drain removal time, need for analgesics, passage of flatus, and length of hospital stay. Methods: A total of 247 patients who underwent tRARP by 2 different experienced surgeons were included in the study. At the end of the tRARP procedure, 1 surgeon performed peritoneal re-approximation (Group 1, n = 108), whereas the other performed peritoneal non-approximation (Group 2, n = 139). The effect of the procedures on drain removal time, passage of flatus, need for analgesics, and length of hospital stay were compared between the groups. Results: There was no significant difference between the groups in terms of preoperative parameters including age, body mass index, and preoperative prostate-specific antigen levels (P > .05) (P = .622, P = .126 and P = .591, respectively). No statistically significant difference was found between the two groups in terms of comorbidity, Gleason score, clinical stage, and lymph node dissection (P = .086, P = .344, P = .318, P = .587, respectively). There was no statistically significant difference between the groups in terms of drain removal time, need for analgesics, passage of flatus, and length of hospital stay (P = .095, P = .142, P = 95, P = .389, respectively). Conclusion: This study did not demonstrate any additional postoperative benefit of peritoneal re-approximation. It has been shown that peritoneal re-approximation has no effect on the length of hospital stay, the need for pain relievers, and passage of flatus, drain duration, day. Therefore, we do not recommend re-approximation of the peritoneum.
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Affiliation(s)
- Selim Tas
- Department of Urology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ali Erhan Eren
- Department of Urology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Ekrem Islamoğlu
- Department of Urology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Salih Polat
- Department of Urology, Amasya University, Amasya, Turkey
| | - Mutlu Ateş
- Department of Urology, Antalya Education and Research Hospital, Antalya, Turkey
| | - Murat Savaş
- Department of Urology, Antalya Education and Research Hospital, Antalya, Turkey
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Bastawrous AL, Brockhaus KK, Chang MI, Milky G, Shih IF, Li Y, Cleary RK. A national database propensity score-matched comparison of minimally invasive and open colectomy for long-term opioid use. Surg Endosc 2021; 36:701-710. [PMID: 33569727 PMCID: PMC8741658 DOI: 10.1007/s00464-021-08338-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/21/2021] [Indexed: 12/11/2022]
Abstract
Background Opioid dependence is a public health crisis and surgery is a risk factor for long-term opioid use. Though minimally invasive surgery (MIS) is associated with less perioperative pain, demonstrating an association with less long-term opioid use would be another reason to justify adoption of minimally invasive techniques. We compared the rates for long-term opioid prescriptions among patients in a large national database who underwent minimally invasive and open colectomy. Methods Using the MarketScan Database, we retrospectively analyzed patients undergoing colon resection for benign and malignant diseases between 2013 and 2017. Among opioid-naïve patients who had ≥ 1 opioid prescriptions filled perioperatively (30 days before surgery to 14 days after discharge), propensity score matching was applied for group comparisons [open (OS) versus MIS, and laparoscopic (LS) versus robotic-assisted surgery (RS)]. The primary outcome was long-term opioid use defined as the proportion of patients with ≥ 1 long-term opioid prescriptions filled 90–180 days after discharge. Risks factors for long-term opioid use were assessed using logistic regression. Results Among the 5413 matched pairs in the MIS versus OS cohorts, MIS significantly reduced long-term opioid use of ‘any opioids’ (13.3% vs. 20.9%), schedule II/III opioids (11.7% vs. 19.2%), and high-dose opioids (4.3% vs. 7.7%; all p < 0.001). Among the 1195 matched pairs in the RS versus LS cohorts, RS was associated with less high-dose opioids (2.1% vs. 3.8%, p = 0.015) 90–180 days after discharge. Other risk factors for long-term opioid use included younger age, benign indications, tobacco use, mental health conditions, and > 6 Charlson comorbidities. Conclusion Minimally invasive colectomy is associated with a significant reduction in long-term opioid use when compared to OS. Robotic-assisted colectomy was associated with less high-dose opioids compared to LS. Increasing adoption of minimally invasive surgery for colectomy and including RS, where appropriate, may decrease long-term opioid use. Supplementary Information The online version contains supplementary material available at 10.1007/s00464-021-08338-9.
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Affiliation(s)
| | - Kara K Brockhaus
- Inpatient Pharmacy, St. Joseph Mercy Hospital Ann Arbor, Ann Arbor, MI, USA
| | - Melissa I Chang
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI, 48106,, USA
| | - Gediwon Milky
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA.,Department of Pharmacy Practice, Purdue University, West Lafayette, IN, USA
| | - I-Fan Shih
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA
| | - Yanli Li
- Global Health Economics and Outcomes Research, Intuitive Surgical, Inc., Sunnyvale, CA, USA
| | - Robert K Cleary
- Department of Surgery, St. Joseph Mercy Hospital Ann Arbor, 5325 Elliott Dr. Suite 104, Ann Arbor, MI, 48106,, USA.
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Britton CJ, Findlay BL, Parikh N, Kohler T, Helo S, Ziegelmann MJ. Long-acting liposomal bupivacaine and postoperative opioid use after Peyronie's disease surgery: a pilot study. Transl Androl Urol 2021; 10:174-183. [PMID: 33532307 PMCID: PMC7844478 DOI: 10.21037/tau-20-871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Background Novel strategies have been proposed to minimize postoperative opioid use, yet many patients experience significant pain after penile surgery. Our objective was to evaluate postoperative opioid use in patients undergoing penile ring block with long-acting liposomal bupivacaine (LB; Exparel) during surgery for Peyronie's disease (PD). Methods We identified patients who underwent tunica albuginea plication (TAP) and plaque excision/grafting (PEG) for PD between July 2019 and September 2020. Intraoperatively, a ring block was administered at the penile base penis with 20 cc of LB. Patients were instructed to use over the counter pain medications as first line treatment for postoperative pain, and opioids were available for severe breakthrough pain as needed [7.5 oral morphine equivalents (OME) =5 mg oxycodone]. Opioid use was assessed during the first five days postoperatively. Results In total, 28 patients met inclusion criteria including 18/28 (64%) who underwent TAP and 10/28 (36%) who underwent PEG. Median patient age was 56 years (IGR 51;61). Median postoperative 10-point visual analogue pain score was 0 (range 0-3). Duration of penile anesthesia ranged from 1.5-4 days. In total, 9/28 patients (32%) utilized opioids during the first five days postoperatively (range 7.5-75 OME). Two patients (7%) required opioids during the first two days after surgery. 27/28 (96%) were satisfied or highly satisfied with postoperative pain control. Conclusions Intraoperative penile ring block with LB resulted in excellent pain control with local anesthetic duration of 1.5-4 days. The majority of patients did not require any opioids during the early postoperative period. Further study comparing outcomes with shorter-acting local anesthetics is necessary to balance pain control benefits with additional cost.
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Affiliation(s)
| | | | - Niki Parikh
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Tobias Kohler
- Department of Urology, Mayo Clinic, Rochester, MN, USA
| | - Sevann Helo
- Department of Urology, Mayo Clinic, Rochester, MN, USA
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Stakeholder Perspective on Opioid Stewardship After Prostatectomy: Evaluating Barriers and Facilitators From the Pennsylvania Urology Regional Collaborative. Urology 2020; 145:120-126. [DOI: 10.1016/j.urology.2020.05.096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2020] [Revised: 05/25/2020] [Accepted: 05/28/2020] [Indexed: 02/01/2023]
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Ziegelmann MJ, Findlay BL, Britton CJ, Habermann EB. Opioid prescribing after urologic surgery: we are part of the problem and part of the solution-an invited commentary on "an opioid prescription for men undergoing minor urologic surgery is associated with an increased risk of new persistent opioid use". Transl Androl Urol 2020; 9:997-1000. [PMID: 32676382 PMCID: PMC7354322 DOI: 10.21037/tau-2020-05] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Affiliation(s)
| | | | | | - Elizabeth B Habermann
- The Robert D. and Patricia E. Kern Center for the Science of Healthcare Delivery Surgical Outcomes Program, Mayo Clinic, Rochester, MN, USA
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