Predicting procedural pain after ureteroscopy: does hydrodistention play a role?

Foley catheter after ureteroscopy and JJ stent placement: a randomised prospective European Association of Urology Section of Urolithiasis-Young Academic Urologists (EULIS-YAU) endourology study

OBJECTIVES

To evaluate the effects of inserting a Foley catheter after ureteroscopy (URS) and JJ stent placement on pain scores, voiding patterns, biochemical parameters and postoperative complications.

PATIENTS AND METHODS

A randomised clinical trial (1:1) with adult patients following unilateral URS + JJ stent placement was planned. In Group A, no Foley catheter was placed, in Group B, a Foley catheter was placed following URS + JJ stent placement. The primary objective was to evaluate effect of placing a Foley catheter on International Prostate Symptom Score (IPSS), Ureteric Stent Symptom Questionnaire (USSQ) score and postoperative biochemical parameters. The secondary objective was to evaluate postoperative complications.

RESULTS

A total of 112 patients were included (56/group). A ureteric access sheath was used in each patient. Patients had similar demographic and surgical parameters. The pre- and postoperative biochemical analyses including white blood cell count, C-reactive protein, procalcitonin and creatinine levels were similar between the two groups. The IPSS were similar between the two groups. All the subdomains of the USSQ were similar between two groups except Total Body Pain score, which was lower in Group B. The visual analogue scale scores were similar. Complications were all Clavien-Dindo Grade I and II, and the complication rate was 5.4% and 8.9% in Group A and B, respectively.

CONCLUSION

Placing a Foley catheter following URS + JJ stent placement did not show significant effects on postoperative biochemical parameters and voiding symptoms. However, a Foley catheter lowered the Total Body Pain score on the USSQ without having significant effects on VAS scores. The practice of placing a Foley catheter following URS and JJ stent placement should be based on surgeon's preference keeping in mind the potential positive effect on pain scores.

Risk Factors for Increased Stent-associated Symptoms Following Ureteroscopy for Urinary Stones: Results From STENTS

PURPOSE

The STudy to Enhance uNderstanding of sTent-associated Symptoms sought to identify risk factors for pain and urinary symptoms, as well as how these symptoms interfere with daily activities after ureteroscopy for stone treatment.

MATERIALS AND METHODS

This prospective observational cohort study enrolled patients aged ≥12 years undergoing ureteroscopy with ureteral stent for stone treatment at 4 clinical centers. Participants reported symptoms at baseline; on postoperative days 1, 3, 5; at stent removal; and day 30 post-stent removal. Outcomes of pain intensity, pain interference, urinary symptoms, and bother were captured with multiple instruments. Multivariable analyses using mixed-effects linear regression models were identified characteristics associated with increased stent-associated symptoms.

RESULTS

A total of 424 participants were enrolled. Mean age was 49 years (SD 17); 47% were female. Participants experienced a marked increase in stent-associated symptoms on postoperative day 1. While pain intensity decreased ∼50% from postoperative day 1 to postoperative day 5, interference due to pain remained persistently elevated. In multivariable analysis, older age was associated with lower pain intensity (P = .004). Having chronic pain conditions (P < .001), prior severe stent pain (P = .021), and depressive symptoms at baseline (P < .001) were each associated with higher pain intensity. Neither sex, stone location, ureteral access sheath use, nor stent characteristics were drivers of stent-associated symptoms.

CONCLUSIONS

In this multicenter cohort, interference persisted even as pain intensity decreased. Patient factors (eg, age, depression) rather than surgical factors were associated with symptom intensity. These findings provide a foundation for patient-centered care and highlight potential targets for efforts to mitigate the burden of stent-associated symptoms.

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.

Quality of life impact and recovery after ureteroscopy and stent insertion: insights from daily surveys in STENTS

BACKGROUND

Our objective was to describe day-to-day evolution and variations in patient-reported stent-associated symptoms (SAS) in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS), a prospective multicenter observational cohort study, using multiple instruments with conceptual overlap in various domains.

METHODS

In a nested cohort of the STENTS study, the initial 40 participants having unilateral ureteroscopy (URS) and stent placement underwent daily assessment of self-reported measures using the Brief Pain Inventory short form, Patient-Reported Outcome Measurement Information System measures for pain severity and pain interference, the Urinary Score of the Ureteral Stent Symptom Questionnaire, and Symptoms of Lower Urinary Tract Dysfunction Research Network Symptom Index. Pain intensity, pain interference, urinary symptoms, and bother were obtained preoperatively, daily until stent removal, and at postoperative day (POD) 30.

RESULTS

The median age was 44 years (IQR 29,58), and 53% were female. The size of the dominant stone was 7.5 mm (IQR 5,11), and 50% were located in the kidney. There was consistency among instruments assessing similar concepts. Pain intensity and urinary symptoms increased from baseline to POD 1 with apparent peaks in the first 2 days, remained elevated with stent in situ, and varied widely among individuals. Interference due to pain, and bother due to urinary symptoms, likewise demonstrated high individual variability.

CONCLUSIONS

This first study investigating daily SAS allows for a more in-depth look at the lived experience after URS and the impact on quality of life. Different instruments measuring pain intensity, pain interference, and urinary symptoms produced consistent assessments of patients' experiences. The overall daily stability of pain and urinary symptoms after URS was also marked by high patient-level variation, suggesting an opportunity to identify characteristics associated with severe SAS after URS.

Evaluating predictive factor of Systemic Inflammatory Response Syndrome and Postoperative Pain in Patients Without Ureteral Stent Placement After Ureteral Access Sheath Use in Flexible Ureteroscopy for Stone Management

BACKGROUND AND OBJECTIVE

This retrospective cohort study aimed to evaluate the safety of stentless flexible ureteroscopy (fURS) using a ureteral access sheath (UAS) for stone management.

PATIENTS AND METHODS

A total of 270 ureteral stentless postoperative patients were analyzed. Stentless indication was characterized by having no ureteral wall or mucosa injury with only slight erosion, < 1-hour operative time, and no endoscopic stone fragments with or without stone dust. Postoperative complications and pain were analyzed for safety measurements. In addition, preoperative and intraoperative risk factors associated with the incidence of systemic inflammatory response syndrome (SIRS) and postoperative pain were evaluated.

RESULTS

The most common UAS sizes were 10/12 Fr (69.6%) and 9.5/11.5 Fr (28.1%). The rate of patients who were stone-free was 95.9%. The median operation time was 34 min. Only three grade 1 ureteral injuries occurred intraoperatively. Postoperative SIRS occurred in 8.8% of patients, and postoperative use of analgesics was 35.9%. Only four patients were required to undergo eventual ureteral stenting. Less than 10/12-Fr UAS was the only factor positively associated with preventing postoperative SIRS (odds ratio [OR], 4.733; 95% confidence interval [CI], 1.085-20.644). Older age and preoperative ureteral stenting were positively associated with preventing postoperative pain (OR, 0.970; 95% CI, 0.951-0.990 and OR, 0.427; 95% CI, 0.232-0.786; respectively).

CONCLUSION

Stentless fURS with UAS in stone management was feasible for selected patients. UAS size of < 10/12 Fr, older age, and preoperative stenting are possible keystones to achieving stentless fURS with UAS postoperatively.

Assessment of Patient and Surgical Variables Including Residency Training Level on Adverse Events After Ureteroscopy for Ureteral Stones: A Multivariate Analysis

PURPOSE

With advances in technology, ureteroscopy (URS) is increasingly utilized for the management of urolithiasis. Previous studies have attempted to characterize the post-operative complication and readmission rates relative to the technical difficulty of the procedure. There is limited data exploring the resident level of training and its effect on adverse outcomes in these cases. We review our experience with URS to create a model to predict factors, including resident experience, that affect rates of post-operative complications.

MATERIALS AND METHODS

We reviewed ureteroscopies performed at our academic facility from January 2009 to December 2013. Ureteral-only stones were examined for demographics, stone characteristics, operative techniques, and resident training level. Post-operative adverse events requiring urology consultation, clinic or emergency department visits, hospital admission, prolonged post-operative hospitalization, or unplanned repeat surgery within 30 days of the procedure were identified and analyzed.

RESULTS

Four hundred seventeen cases of URS for ureteral-only stones were included for study. We identified 53 (12.7%) involving an unexpected post-operative course. Several logistic regression models were created to make a predictive model of adverse events. One model found only lack of stone clearance to be significant for increasing the likelihood of an adverse event. A second model determined that no residency year showed higher odds of adverse outcomes.

CONCLUSIONS

URS has increased in prevalence in recent years, but overall complication rates are low. Resident level of experience does not appear to impact adverse event rate. Stone clearance during initial surgery appears to be the most important in avoiding adverse events. Further expansion of the database over time will improve our ability to predict adverse outcomes in this common procedure.