Category: Clinical Stones: Ureteroscopy
Introduction & Objective :
Efforts have begun to implement non-opioid protocols for outpatient urologic surgery. Previously, we reported that ureteroscopy with stent placement (URS) is feasible without postoperative opioids. In this study, we report our longer term follow-up with this approach and looked to identify factors associated with those requiring opioids postoperatively to help guide future management pathways.
Methods : Retrospective review of patients who underwent URS by a single surgeon over a 15 month period from November 2016 to March 2018 was conducted. Efforts were made to substitute opioids for either no prescription or diclofenac, an NSAID. All patients having normal renal function and no evidence of opioid tolerance were eligible for the non-opioid protocol but were not prevented from discharge with opioids if necessary. Feasibility was evaluated by measuring the frequency of postoperative adverse events including visits to the emergency room (ER) for stent-related symptoms (SRS’s), stent-related clinic telephone calls, and requests for prescription refills for pain medication in those who received opioids and those who did not.
Results : 206 patients underwent URS: 151 patients were discharged without opioids (73%) and 55 received opioids (27%). Of those without opioids, 129 received diclofenac and 22 received no pain medication. A similar percentage of patients in each group had ER visits for SRS’s (7 receiving opioids (13%) and 15 without opioids (10%); p=0.57). Patients without opioids made significantly fewer telephone calls (25 patients receiving opioids (45%) and 32 patients without opioids (21%); p≤.001). The number of pain medication refill requests was also fewer among patients given non-opioids (13 patients receiving opioids (24%) and 11 patients without opioids (7%); p=0.001). Factors associated with receiving opioids on univariate analysis were BMI (p=.006), CKD > stage II (p=.002), solitary kidney (p=.005), fibromyalgia (p=.006), and chronic pain (p=.006). On multivariate analysis, BMI, CKD, and fibromyalgia were significantly associated.
Conclusions : Our experience using a non-opioid pathway post URS reveals that approximately 3/4 of patients can be discharged without opioids. Compared to patients receiving opioids, patients receiving non-opioid therapies had similar postoperative adverse events with overall lower impact on outpatient resource utilization. Factors associated with patients receiving opioids postoperatively were CKD stage > II, BMI, and fibromyalgia on multivariate analysis.
David Sobel– Urology Resident, University of Vermont, Burlington, Vermont
Tessa Barclay– medical student, University of Vermont, Burlington, Vermont
Theodore Cisu– medical student, University of Vermont, Burlington, Vermont
Peter Callas– Research Assistant Professor, Medicine, University of Vermont, Burlington, Vermont
Kevan Sternberg– Assistant Professor, Urology, University of Vermont, Burlington, Vermont
Research Assistant Professor, Medicine
University of Vermont