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Liu H, Fu X, Ren YF, Tan SY, Xiang SR, Zheng C, You FM, Shi W, Li LJ. Does Inhaled Methoxyflurane Implement Fast and Efficient Pain Management in Trauma Patients? A Systematic Review and Meta-Analysis. Pain Ther 2021; 10:651-674. [PMID: 33837931 PMCID: PMC8119536 DOI: 10.1007/s40122-021-00258-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 03/16/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction Evidence on the use of inhaled methoxyflurane in the management of trauma pain is conflicting and obfuscated. This study aimed to determine the efficacy and safety of inhaled methoxyflurane for trauma pain on the basis of published randomized controlled trials (RCTs). Methods RCTs assessing the efficacy of methoxyflurane in adults or adolescents with acute trauma pain published in PubMed, Web of Science, Embase, Cochrane Library, and Google Scholar were searched. The control groups were those that received placebo or standard analgesic treatment (SAT). The primary outcome was the change from baseline in pain scores during the first 30 min of treatment. Secondary outcomes included time to first pain relief, the proportion of patients experiencing pain relief, rescue analgesia rate, the treatment satisfaction of patients and investigators, and the methoxyflurane-related treatment-emergent adverse events (TEAEs). Results A total of nine RCTs (1806 patients) were identified. Results revealed that methoxyflurane provided a clinically unimportant benefit by improving the mean difference of change from baseline in pain intensity (from − 0.44 to − 1.23 cm, p < 0.001) at various time points within the first 20 min compared to control treatment. Besides, methoxyflurane decreased the time of onset of pain relief (mean difference − 5.29 min; 95% CI − 6.97 to − 3.62) and the proportion of patients who needed rescue analgesic medication (risk ratio 1.41; 95% CI 1.17–1.70) despite it increasing the risk of non-severe TEAEs (risk ratio 3.09; 95% CI 1.72–5.57). Notably, the benefit of almost all secondary pain-related outcomes was rendered clinically nonsignificant between methoxyflurane and SAT strata besides the time of onset of pain relief. The quality of evidence was low or very low in all outcomes. Conclusions In emergency situations without effective therapy, this systematic review and meta-analysis provides low-quality evidence that methoxyflurane can be used as a rapid-acting and effective treatment for acute trauma pain, although its utilization is associated a risk of non-severe TEAEs. However, the current evidence does not support the notion that inhaled methoxyflurane offered superior analgesic efficacy to SAT. Clinical Trial Number PROSPERO registration number CRD42020223000. Supplementary Information The online version contains supplementary material available at 10.1007/s40122-021-00258-9.
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Affiliation(s)
- Hong Liu
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Xi Fu
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Yi-Feng Ren
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China.
| | - Shi-Yan Tan
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Si-Rui Xiang
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Chuan Zheng
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Feng-Ming You
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China
| | - Wei Shi
- Department of Anesthesiology, West China Hospital, Sichuan University and the Research Units of West China (2018RU012), Chinese Academy of Medical Sciences, Chengdu, 610041, China.
| | - Lin-Jiong Li
- Hospital of Chengdu University of Traditional Chinese Medicine, No. 39 Shi-er-qiao Road, Chengdu, 610072, Sichuan Province, China.
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Schoenthaler M, Hein S, Wilhelm K, Pohlmann PF, Praus F, Walther T, Schmoor C, Gratzke C, Miernik A. Feasibility of an Updated Randomised Controlled Trial on Surgical Urolithiasis Treatments: The Pilot Trial for the German Endoscopic versus Shock Wave Therapy Study (GESS). Eur Urol Focus 2021; 8:271-275. [PMID: 33500235 DOI: 10.1016/j.euf.2021.01.001] [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: 10/16/2020] [Revised: 12/15/2020] [Accepted: 01/06/2021] [Indexed: 11/28/2022]
Abstract
Data comparing treatments for urolithiasis are often outdated, with inconsistent results or poor methodological and reporting quality. We report a pilot study in preparation for a larger multicentre randomised controlled trial (RCT) comparing shockwave therapy and ureteroscopy in patients with a single urinary stone of ≤20 mm in the upper urinary tract. Primary objectives included screening completeness, patients' willingness to participate, their remaining in the study, the suitability of the eligibility criteria, and the acceptability of the outcome measures. Screened individuals not invited to participate were those with no indication for active treatment among referred patients (n = 166), those who staff failed to screen (n = 99), and patients not meeting the inclusion criterion of a single stone (n = 422). Of the 176 patients invited, 116 refused to participate. Ultimately, we were able to recruit 60 patients within 34 mo. All patients underwent their allocated treatments. This pilot trial provides an in-depth analysis of the feasibility of an RCT on surgical treatments for upper urinary tract urolithiasis in a highly regulated health care system. The study procedures and outcome measures proved acceptable and feasible. On the basis of these data, we propose a pragmatic, multicentre RCT to deliver updated, high-level evidence on the efficacy of currently available treatments for urolithiasis. PATIENT SUMMARY: We performed a small pilot trial comparing current treatments in urolithiasis. We were able to prove the feasibility of a larger multi-institutional trial with regard to the time needed to recruit an adequate number of patients and the acceptability of the treatments and outcome measures.
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Affiliation(s)
- Martin Schoenthaler
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany.
| | - Simon Hein
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Konrad Wilhelm
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Philippe-Fabian Pohlmann
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Friederike Praus
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Tabea Walther
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Claudia Schmoor
- Clinical Trials Unit, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Christian Gratzke
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arkadiusz Miernik
- Department of Urology, Medical Centre - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Tan BY, Pereira MJ, Yang SY, Hunter DJ, Skou ST, Thumboo J, Car J. Collaborative model of care between Orthopaedics and allied healthcare professionals in knee osteoarthritis (CONNACT): study protocol for an effectiveness-implementation hybrid randomized control trial. BMC Musculoskelet Disord 2020; 21:684. [PMID: 33066746 PMCID: PMC7568411 DOI: 10.1186/s12891-020-03695-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 10/01/2020] [Indexed: 11/29/2022] Open
Abstract
Background Knee Osteoarthritis (OA) is a leading cause of global disability. The Collaborative Model of Care between Orthopaedics and Allied Healthcare Professionals (CONNACT) Model of Care (MoC) was developed by optimizing evidence-based non-surgical treatments to deliver value-based care for people with knee OA. The primary aim of this study is to determine the clinical effectiveness of the CONNACT MoC (3 months) compared to usual care. The secondary aims are: a) To determine the cost-effectiveness and b) To develop an evaluation and implementation framework to inform large scale implementation for this MoC. Methodology Type 1 Effectiveness-Implementation Hybrid Trial using an explanatory sequential mixed-method approach. The study consists of 3 components. The first component is the pragmatic, parallel-arm, single-blinded randomized control trial. Inclusion criteria are patients with knee OA based on the National Institute of Health and Care Excellence (NICE) criteria with radiographic severity of greater than Kellgren-Lawrence 1, and Knee Injury and OA Outcome Score (KOOS4) of equal or less than 75. Exclusion criteria include other forms of arthritis, history of previous knee arthroplasty or wheelchair-bound patient. KOOS4 is the primary outcome measure at 3 months, 6 months and 1 year. Secondary outcomes include KOOS individual subscales, quality of life scoring, functional performance, global, diet and psychological related outcomes. The second component is an economic evaluation of the cost-effectiveness of the CONNACT MoC using a societal perspective. The third component is an implementation and evaluation framework using process evaluation under the RE-AIM framework using a mixed-method approach. Sample size of 100 patients has been calculated. Discussion CONNACT MoC is a complex intervention. In line with the MRC guidance for developing and evaluating complex interventions, a pilot feasibility study was completed and a comprehensive approach including an RCT, economic evaluation and process evaluation is described in this study protocol. Results from this study will help clinicians, healthcare administrators and policymakers guide the sustainable and effective implementation of the CONNACT MoC for knee OA and serve as a basis for similar multidisciplinary MoC for chronic degenerative musculoskeletal conditions to be developed. Trial registration Clinicaltrials.gov Identifier: NCT03809975. Registered January 182,019.
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Affiliation(s)
- Bryan Yijia Tan
- Department of Orthopaedic Surgery, Woodlands Health Campus, National Healthcare Group, Singapore, Singapore. .,Singapore General Hospital, Singapore City, Singapore.
| | | | - Su-Yin Yang
- Department of Orthopaedic Surgery, Woodlands Health Campus, National Healthcare Group, Singapore, Singapore.,Tan Tock Seng Hospital, Singapore City, Singapore
| | - David J Hunter
- Institute of Bone and Joint Research, Kolling Institute, University of Sydney and Rheumatology Department, Royal North Shore Hospital, Sydney, Australia
| | - Soren Thorgaard Skou
- Department of Sports Science and Clinical Biomechanics, Research Unit for Musculoskeletal Function and Physiotherapy, University of Southern Denmark, Odense M, Denmark.,Department of Physiotherapy and Occupational Therapy, Næstved-Slagelse-Ringsted Hospitals, Slagelse, Denmark
| | | | - Josip Car
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore City, Singapore
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Park SK, Yoon S, Kim BR, Choe SH, Bahk JH, Seo JH. Pre-emptive epidural analgesia for acute and chronic post-thoracotomy pain in adults: a systematic review and meta-analysis. Reg Anesth Pain Med 2020; 45:1006-1016. [DOI: 10.1136/rapm-2020-101708] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Revised: 09/14/2020] [Accepted: 09/16/2020] [Indexed: 01/03/2023]
Abstract
Background and objectivesEpidural analgesia is the gold standard for post-thoracotomy pain management and can be started before or after surgical incision. This systematic review and meta-analysis investigated whether pre-emptive epidural analgesia before thoracotomy incision reduces acute and chronic post-thoracotomy pain in adults compared with epidural analgesia after incision.MethodsWe searched databases including MEDLINE, Embase, and CENTRAL for randomized controlled trials comparing epidural analgesia initiated before (pre-emptive group) and after (control group) thoracotomy incision in adults. The primary outcomes were the pain intensity during rest and coughing within 72 hours after surgery and the incidence of pain 1 to 6 months after surgery. Data were combined with random-effects meta-analyses. We rated the quality of evidence as high, moderate, low, and very low using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) method.ResultsWe included 19 trials with 1062 participants involving 529 in the pre-emptive group and 533 in the control group. The pain intensity was significantly lower at rest within 72 hours after surgery (19 studies, n=1062) and during coughing within 48 hours after surgery (11 studies, n=638), and the incidence of pain was significantly lower 1 to 6 months after surgery (6 studies, n=276) in the pre-emptive group than in the control group. The quality of evidence was moderate or low in the primary outcomes.ConclusionsOur review provides low-quality evidence that pre-emptive epidural analgesia reduces the intensity of acute pain and the incidence of chronic pain after thoracotomy in adults.Protocol registration numberCRD42019131620.
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Wilhelm K, Cazana IM, Schoenthaler M, Katzenwadel A, Spaeth J, Miernik A. Low-pressure monopolar electroresection of the prostate for glands sized > 70 vs. < 70 cc performed with continuous irrigation and suprapubic suction: perioperative and long-term outcome. World J Urol 2018; 36:449-457. [PMID: 29307091 PMCID: PMC5846831 DOI: 10.1007/s00345-017-2162-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Accepted: 12/20/2017] [Indexed: 01/27/2023] Open
Abstract
Purpose To evaluate long-term efficacy and safety of low-pressure transurethral resection of the prostate for prostates < 70 cc (group 1) vs. > 70 cc (group 2). Patients and methods In this study patients operated with monopolar TURP between 2009 and 2012 were evaluated retrospectively. During surgery a specially designed trocar (18 Fr) was placed suprapubically and connected to a suction pump to maintain stable low-pressure conditions. After sample size calculations, long-term follow-up was completed for 70 invited patients in each group up to 9/2015. Results Follow-up period was 57 vs. 56 months for group 1 and 2, respectively (p = 0.56). At baseline there was no significant difference in age, IPSS, peak flow, and post void residual (PVR). Mean prostate volume was 47 cc (15–65) vs. 100 cc (70–163). Mean operating time was 55.4 vs. 82.6 min (p = 0.00). Blood transfusion was necessary in 0.0 vs. 2.9% (p = 0.16), and 0.0 vs. 1.4% developed TUR syndrome (p = 0.32). At follow-up mean relative improvement in IPSS was 63 vs. 57% (p = 0.29), QoL 64 vs. 64% (p = 0.93), peak flow 139 vs. 130% (p = 0.85), and PVR 58 vs. 63% (p = 0.80). Long-term complications included recurring adenoma in 1.4 vs. 4.3% (p = 0.31), and stricture in 7.2 vs. 5.8% (p = 0.73). 1 patient in each group reported worsening incontinence symptoms. Conclusions In terms of safety and efficacy, the aforementioned modality of standardized monopolar TURP using suprapubic suction was non-inferior for prostates > 70 cc compared to the same procedure for prostates < 70 cc. This technique is a potential low-cost alternative for clinics that cannot afford modern laser approaches. Study register number DRKS00006527.
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Affiliation(s)
- Konrad Wilhelm
- Department of Urology, University Medical Center, Hugstetterstr. 55, 79106, Freiburg, Germany.
| | - Ioana Maria Cazana
- Department of Urology, University Medical Center, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Martin Schoenthaler
- Department of Urology, University Medical Center, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Arndt Katzenwadel
- Department of Urology, University Medical Center, Hugstetterstr. 55, 79106, Freiburg, Germany
| | - Johannes Spaeth
- Department of Anesthesiology and Critical Care, Faculty of Medicine, Medical Centre-University of Freiburg, Freiburg, Germany
| | - Arkadiusz Miernik
- Department of Urology, University Medical Center, Hugstetterstr. 55, 79106, Freiburg, Germany
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Evaluation of pain relief sufficiency using the Cumulative Analgesic Consumption Score (CACS) and its modification (MACS). Wideochir Inne Tech Maloinwazyjne 2017; 12:448-454. [PMID: 29362662 PMCID: PMC5776495 DOI: 10.5114/wiitm.2017.72329] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2017] [Accepted: 08/20/2017] [Indexed: 11/17/2022] Open
Abstract
Postoperative pain is one of the major complications in general and bariatric surgery, associated with ongoing problems such as ileus, pneumonia and prolonged mobilization. In this study, patients undergoing bariatric surgery were analyzed according to their postoperative pain relief regime. In one group patients were treated with a patient-controlled analgesia (PCA) device, while the other group was treated with oral and intravenous analgesic medication. The aim of this study was to analyze which postoperative pain relief therapy would be more appropriate. We chose the Cumulative Analgesic Consumption Score (CACS) and Numeric Rating Scale (NRS) for pain measurement. For better comparison, we performed a modification of CACS according to PCA treatment. We observed better pain relief in the PCA group. Furthermore, we observed an advantage of treatment with laxatives in patients treated with PCA. In conclusion, PCA devices are appropriate instruments for postoperative pain relief in bariatric patients. CACS is a practical tool for postoperative pain measurement, describing individual pain sensation more objectively, although holding further potential in modification.
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Naaz S, Shukla U, Srivastava S, Ozair E, Asghar A. A Comparative Study of Analgesic Effect of Intrathecal Nalbuphine and Fentanyl as Adjuvant in Lower Limb Orthopaedic Surgery. J Clin Diagn Res 2017; 11:UC25-UC28. [PMID: 28893017 PMCID: PMC5583890 DOI: 10.7860/jcdr/2017/24385.10224] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2016] [Accepted: 04/06/2017] [Indexed: 11/24/2022]
Abstract
INTRODUCTION Intrathecal opioids when added to local anaesthetics decrease their dosage and provide haemodynamic stability. Nalbuphine is an agonist-antagonist and acts on kappa receptors providing analgesia. AIM The study aims to compare the analgesic efficacy of fentanyl with that of two doses of nalbuphine when used with injection bupivacaine heavy in spinal anaesthesia. MATERIALS AND METHODS A randomised, double blinded, prospective study on 90 patients of ASA I and II undergoing lower limb orthopaedic surgery under subarachnoid block was done. Patients were randomly allocated into three groups (n=30). Each group received 12.5 mg of 0.5% of injection bupivacaine heavy along with either 25 μg of 0.5 ml fentanyl (Group F) or 0.8 mg of 0.5 ml nalbuphine (Group NL) or 1.6 mg of 0.5 ml nalbuphine (Group NH). Characteristics of sensory and motor blocks, haemodynamic changes, duration and quality of analgesia, adverse effects, sedation, VRS score and analgesic requirement were studied at different time interval intraoperatively and till 24 hours of block. RESULTS The duration of analgesia (in minute) was 441±119.69 in NL Group, 450±103.38 in NH Group and 300.0±88.53 in Group F (p=0.05). There was no significant difference regarding block characteristics and haemodynamic parameters. Total 24 hours analgesic requirement was titrated by analgesic score which was 2.25±0.7 (NH Group), 1.875±0.83 (NL Group) and 3.375±1.77 (F Group) p=0.0186 by ANOVA. The adverse effects of NL Group were least. CONCLUSION There was no significant advantage of intrathecal fentanyl or 1.6 mg nalbuphine over low dose 0.8 mg nalbuphine.
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Affiliation(s)
- Shagufta Naaz
- Associate Professor, Department of Anaesthesiology, UPUMS, Etawah, Uttar Pradesh, India
| | - Usha Shukla
- Professor, Department Anaesthesiology, UPUMS, Etawah, Uttar Pradesh, India
| | - Swati Srivastava
- Assistant Professor, Department of Anaesthesiology, UPUMS, Etawah, Uttar Pradesh, India
| | - Erum Ozair
- Senior Resident, Department of Anaesthesiology, JNMC, AMU, Aligarh, Uttar Pradesh, India
| | - Adil Asghar
- Assistant Professor, Department of Anatomy, UPUMS, Etawah, Uttar Pradesh, India
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Ultra-mini PCNL versus flexible ureteroscopy: a matched analysis of analgesic consumption and treatment-related patient satisfaction in patients with renal stones 10-35 mm. World J Urol 2015; 33:2131-6. [PMID: 25971205 DOI: 10.1007/s00345-015-1585-5] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2015] [Accepted: 05/02/2015] [Indexed: 10/23/2022] Open
Abstract
PURPOSE To compare ultra-mini PCNL (UMP) and flexible ureteroscopy (fURS) for the treatment of medium- to large-sized renal stones with a focus on patients' postsurgical cumulative analgesic consumption and treatment-related satisfaction. METHODS Twenty-five patients treated by UMP between April 2013 and October 2014 were matched to data of 25 fURS patients from an existing database. Clinical outcome parameters were recorded prospectively. Postoperative analgesic consumption was assessed using the Cumulative Analgesic Consumption Score (CACS), and satisfaction was measured with the Freiburg Index of Patient Satisfaction (FIPS) questionnaire. RESULTS Perioperative outcome parameters showed no significant differences except for mean operating times (fURS 98.52 min, UMP 130.12 min [p = 0.002]) and hospital stay (fURS 67.2 h, UMP 91.5 h [p = 0.04]). Primary stone-free rate was 96 % in fURS and 92 % in UMP. Complications Clavien grade 2 or 3 occurred in 16 % of UMP patients and in 4 % of fURS patients. Postsurgical cumulative analgesic consumption was almost identical in both groups with CACSs of 6.96 (0-15) for fURS and 6.8 (0-23) for UMP. Patients' satisfaction was high in both techniques: FIPS score in fURS 1.67 (1-3) and 1.73 (1-4) in UMP (scale 1-6). CONCLUSIONS Treatment of medium- to large-sized renal stones is safe and highly effective by both UMP and fURS. Moreover, both treatments yield comparable postsurgical analgesic requirements and high patient satisfaction scores. Patient-related factors (anatomical and stone related) and availability of technical equipment and surgical expertise appear to be the most important determining factors in treatment planning.
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