The Mixoplankton Database (MDB): Diversity of photo-phago-trophic plankton in form, function, and distribution across the global ocean.

Protist plankton are major members of open-water marine food webs. Traditionally divided between phototrophic phytoplankton and phagotrophic zooplankton, recent research shows many actually combine phototrophy and phagotrophy in the one cell; these protists are the "mixoplankton." Under the mixoplankton paradigm, "phytoplankton" are incapable of phagotrophy (diatoms being exemplars), while "zooplankton" are incapable of phototrophy. This revision restructures marine food webs, from regional to global levels. Here, we present the first comprehensive database of marine mixoplankton, bringing together extant knowledge of the identity, allometry, physiology, and trophic interactivity of these organisms. This mixoplankton database (MDB) will aid researchers that confront difficulties in characterizing life traits of protist plankton, and it will benefit modelers needing to better appreciate ecology of these organisms with their complex functional and allometric predator-prey interactions. The MDB also identifies knowledge gaps, including the need to better understand, for different mixoplankton functional types, sources of nutrition (use of nitrate, prey types, and nutritional states), and to obtain vital rates (e.g. growth, photosynthesis, ingestion, factors affecting photo' vs. phago' -trophy). It is now possible to revisit and re-classify protistan "phytoplankton" and "zooplankton" in extant databases of plankton life forms so as to clarify their roles in marine ecosystems.

'Boom-and-busted' dynamics of phytoplankton-virus interactions explain the paradox of the plankton.

Rapid virus proliferation can exert a powerful control on phytoplankton host populations, playing a significant role in marine biogeochemistry and ecology. We explore how marine lytic viruses impact phytoplankton succession, affecting host and nonhost populations. Using an in silico food web we conducted simulation experiments under a range of different abiotic and biotic conditions, exploring virus-host-grazer interactions and manipulating competition, allometry, motility and cyst cycles. Virus-host and predator-prey interactions, and interactions with competitors, generate bloom dynamics with a pronounced 'boom-and-busted' dynamic (BBeD) which leads to the suppression of otherwise potentially successful phytoplankton species. The BBeD is less pronounced at low nutrient loading through distancing of phytoplankton hosts, while high sediment loading and high nonhost biomass decrease the abundance of viruses through adsorption. Larger hosts are inherently more distanced, but motility increases virus attack, while cyst cycles promote spatial and temporal distancing. Virus control of phytoplankton bloom development appears more important than virus-induced termination of those blooms. This affects plankton succession - not only the growth of species infected by the virus, but also those that compete for the same resources and are collectively subjected to common grazer control. The role of viruses in structuring plankton communities via BBeDs can thus provide an explanation for the paradox of the plankton.

Deuterium in marine organic biomarkers: toward a new tool for quantifying aquatic mixotrophy.

The traditional separation between primary producers (autotrophs) and consumers (heterotrophs) at the base of the marine food web is being increasingly replaced by the paradigm that mixoplankton, planktonic protists with the nutritional ability to use both phago(hetero)trophy and photo(auto)trophy to access energy are widespread globally. Thus, many 'phytoplankton' eat, while 50% of 'protozooplankton' also perform photosynthesis. Mixotrophy may enhance primary production, biomass transfer to higher trophic levels and the efficiency of the biological pump to sequester atmospheric CO2 into the deep ocean. Although this view is gaining traction, science lacks a tool to quantify the relative contributions of autotrophy and heterotrophy in planktonic protists. This hinders our understanding of their impacts on carbon cycling within marine pelagic ecosystems. It has been shown that the hydrogen (H) isotopic signature of lipids is uniquely sensitive to heterotrophy relative to autotrophy in plants and bacteria. Here, we explored whether it is also sensitive to the trophic status in protists. The new understanding of H isotope signature of lipid biomarkers suggests it offers great potential as a novel tool for quantifying the prevalence of mixotrophy in diverse marine microorganisms and thus for investigating the implications of the 'mixoplankton' paradigm.

A Bibliometric Analysis of Microalgae Research in the World, Europe, and the European Atlantic Area.

：A bibliographic database of scientific papers published by authors affiliated worldwide, especially focused in Europe and in the European Atlantic Area, and containing the keywords "microalga(e)" or "phytoplankton" was built. A corpus of 79,020 publications was obtained and analyzed using the Orbit Intellixir software to highlight the evolution of the research domain. Publication rates from 1960 to 2019, organization of the research, collaboration networks between countries and organizations, emerging and fading research concepts, major studied species, and associated concepts, as well as journals publishing microalgae research were considered. As a result, of the 79,020 papers published worldwide, 26,137 included authors from Europe (33% of world production) and 6989 from the European Atlantic Area (AA) (27% of European production, 9% of world production). The main worldwide scientific research topics found in this study were phytoplankton, community, bloom, diatoms, distribution, ecosystem, coastal, chlorophyll, zooplankton, photosynthesis, and primary production. At the European scale, the most studied topics were related to the environment, food, chemicals, pigments, protein, feed, and drugs. The highest scientific trends and market opportunities analysis identified bioplastics and biostimulants as top emerging concepts at the European level and agricultural, animal feed, and blue biotechnology at the European AA level.

Effects of growth rate, cell size, motion, and elemental stoichiometry on nutrient transport kinetics.

Nutrient acquisition is a critical determinant for the competitive advantage for auto- and osmohetero- trophs alike. Nutrient limited growth is commonly described on a whole cell basis through reference to a maximum growth rate (Gmax) and a half-saturation constant (KG). This empirical application of a Michaelis-Menten like description ignores the multiple underlying feedbacks between physiology contributing to growth, cell size, elemental stoichiometry and cell motion. Here we explore these relationships with reference to the kinetics of the nutrient transporter protein, the transporter rate density at the cell surface (TRD; potential transport rate per unit plasma-membrane area), and diffusion gradients. While the half saturation value for the limiting nutrient increases rapidly with cell size, significant mitigation is afforded by cell motion (swimming or sedimentation), and by decreasing the cellular carbon density. There is thus potential for high vacuolation and high sedimentation rates in diatoms to significantly decrease KG and increase species competitive advantage. Our results also suggest that Gmax for larger non-diatom protists may be constrained by rates of nutrient transport. For a given carbon density, cell size and TRD, the value of Gmax/KG remains constant. This implies that species or strains with a lower Gmax might coincidentally have a competitive advantage under nutrient limited conditions as they also express lower values of KG. The ability of cells to modulate the TRD according to their nutritional status, and hence change the instantaneous maximum transport rate, has a very marked effect upon transport and growth kinetics. Analyses and dynamic models that do not consider such modulation will inevitably fail to properly reflect competitive advantage in nutrient acquisition. This has important implications for the accurate representation and predictive capabilities of model applications, in particular in a changing environment.

Prevalence of Post-Micturition Incontinence before and after Anterior Urethroplasty.

PURPOSE: In this study we aimed to define the prevalence of preoperative and postoperative post-micturition incontinence or post-void dribbling after anterior urethroplasty for urethral stricture disease. We also sought to determine risk factors for its presence. MATERIALS AND METHODS: We retrospectively reviewed a prospectively maintained, multi-institutional urethral stricture database to evaluate post-micturition incontinence using a single question from a validated questionnaire, "How often have you had a slight wetting of your pants a few minutes after you had finished urinating and had dressed yourself?" Possible answers were never-0 to all the time-3. The presence of post-micturition incontinence was defined as any answer greater than 0. Comparisons were made to stricture type and location, repair type and patient medical comorbidities. RESULTS: Preoperative and postoperative post-micturition incontinence questionnaires were completed by 614 and 331 patients, respectively. Patients without complete data available were excluded from study. Preoperative post-micturition incontinence was present in 73% of patients, of whom 44% stated that this symptom was present most of the time. Overall postoperative post-micturition incontinence was present in 40% of patients and again it was not predicted by stricture location or urethroplasty type. Of the 331 patients with followup questionnaires 60% reported improvement, 32% reported no change and 8% reported worsening symptoms. The overall rate of de novo post-micturition incontinence was low at 6.3%. CONCLUSIONS: The prevalence of preoperative post-micturition incontinence is high and likely under reported. In most patients post-micturition incontinence improves after urethroplasty and the prevalence of de novo post-micturition incontinence is low. The presence of post-micturition incontinence was not predicted by stricture length or location, or urethroplasty repair type.

The role of coccolithophore calcification in bioengineering their environment.

Coccolithophorids are enigmatic plankton that produce calcium carbonate coccoliths, which over geological time have buried atmospheric CO2 into limestone, changing both the atmosphere and geology of the Earth. However, the role of coccoliths for the proliferation of these organisms remains unclear; suggestions include roles in anti-predation, enhanced photosynthesis and sun-screening. Here we test the hypothesis that calcification stabilizes the pH of the seawater proximate to the organisms, providing a level of acidification countering the detrimental basification that occurs during net photosynthesis. Such bioengineering provides a more stable pH environment for growth and fits the empirical evidence for changes in rates of calcification under different environmental conditions. Under this scenario, simulations suggest that the optimal production ratio of inorganic to organic particulate C (PIC : POCprod) will be lower (by approx. 20%) with ocean acidification and that overproduction of coccoliths in a future acidified ocean, where pH buffering is weaker, presents a risk to calcifying cells.

Ocean acidification with (de)eutrophication will alter future phytoplankton growth and succession.

Human activity causes ocean acidification (OA) though the dissolution of anthropogenically generated CO2 into seawater, and eutrophication through the addition of inorganic nutrients. Eutrophication increases the phytoplankton biomass that can be supported during a bloom, and the resultant uptake of dissolved inorganic carbon during photosynthesis increases water-column pH (bloom-induced basification). This increased pH can adversely affect plankton growth. With OA, basification commences at a lower pH. Using experimental analyses of the growth of three contrasting phytoplankton under different pH scenarios, coupled with mathematical models describing growth and death as functions of pH and nutrient status, we show how different conditions of pH modify the scope for competitive interactions between phytoplankton species. We then use the models previously configured against experimental data to explore how the commencement of bloom-induced basification at lower pH with OA, and operating against a background of changing patterns in nutrient loads, may modify phytoplankton growth and competition. We conclude that OA and changed nutrient supply into shelf seas with eutrophication or de-eutrophication (the latter owing to pollution control) has clear scope to alter phytoplankton succession, thus affecting future trophic dynamics and impacting both biogeochemical cycling and fisheries.

Primary renal extra-osseous osteosarcoma.

Primary renal extra-osseous osteosarcoma is an exceedingly rare and deadly kidney neoplasm with only 27 reported cases to date. Extra-osseous osteosarcoma is a mesenchymal sarcoma that produces osteoid, but has no skeletal or periosteal involvement and most commonly arises in the lower extremities. Yet, it can arise in other locations such as the kidney. Extra-osseous osteosarcoma behaves as a separate entity from osseous osteosarcoma and should be treated as such. The treatment is surgical resection. Five year overall survival is 46% for local and 10% for metastatic disease. Additionally, 45%-50% of patients experience disease recurrence. We present a 77-year-old woman who underwent work up for recurrent gross hematuria and subsequently underwent radical nephroureterectomy for presumed upper tract urothelial cell carcinoma. However, pathologic analysis revealed a diagnosis of primary renal extra-osseous osteosarcoma. She is alive with no evidence of disease 30 months after surgery.

Have we been underestimating the effects of ocean acidification in zooplankton?

Understanding how copepods may respond to ocean acidification (OA) is critical for risk assessments of ocean ecology and biogeochemistry. The perception that copepods are insensitive to OA is largely based on experiments with adult females. Their apparent resilience to increased carbon dioxide (pCO2 ) concentrations has supported the view that copepods are 'winners' under OA. Here, we show that this conclusion is not robust, that sensitivity across different life stages is significantly misrepresented by studies solely using adult females. Stage-specific responses to pCO2 (385-6000 µatm) were studied across different life stages of a calanoid copepod, monitoring for lethal and sublethal responses. Mortality rates varied significantly across the different life stages, with nauplii showing the highest lethal effects; nauplii mortality rates increased threefold when pCO2 concentrations reached 1000 µatm (year 2100 scenario) with LC50 at 1084 µatm pCO2 . In comparison, eggs, early copepodite stages, and adult males and females were not affected lethally until pCO2 concentrations ≥3000 µatm. Adverse effects on reproduction were found, with >35% decline in nauplii recruitment at 1000 µatm pCO2 . This suppression of reproductive scope, coupled with the decreased survival of early stage progeny at this pCO2 concentration, has clear potential to damage population growth dynamics in this species. The disparity in responses seen across the different developmental stages emphasizes the need for a holistic life-cycle approach to make species-level projections to climate change. Significant misrepresentation and error propagation can develop from studies which attempt to project outcomes to future OA conditions solely based on single life history stage exposures.

Variation in elemental stoichiometry of the marine diatom Thalassiosira weissflogii (Bacillariophyceae) in response to combined nutrient stress and changes in carbonate chemistry.

The combined consequences of the multi-stressors of pH and nutrient availability upon the growth of a marine diatom were investigated. Thalassiosira weissflogii was grown in N- or P-limited batch culture in sealed systems, with pH commencing at 8.2 ("extant" conditions) or 7.6 ("ocean acidification" [OA] conditions), and then pH was allowed to either drift with growth, or was held fixed. Results indicated that within the pH range tested, the stability of environmental pH rather than its value (i.e., OA vs. extant) fundamentally influenced biomass accumul-ation and C:N:P stoichiometry. Despite large changes in total alkalinity in the fixed pH systems, final biomass production was consistently greater in these systems than that in drifting pH systems. In drift systems, pH increased to exceed pH 9.5, a level of alkalinity that was inhibitory to growth. No statis-tically significant differences between pH treatments were measured for N:C, P:C or N:P ratios during nutrient-replete growth, although the diatom expre-ssed greater plasticity in P:C and N:P ratios than in N:C during this growth phase. During nutrient-deplete conditions, the capacity for uncoupled carbon fixa-tion at fixed pH was considerably greater than that measured in drift pH systems, leading to strong contrasts in C:N:P stoichiometry between these treatments. Whether environmental pH was stable or drifted directly influenced the extent of physiological stress. In contrast, few distinctions could be drawn between "extant" versus "OA" conditions for cell physiology.

Feeding in mixoplankton enhances phototrophy increasing bloom-induced pH changes with ocean acidification.

Plankton phototrophy consumes CO2, increasing seawater pH, while heterotrophy does the converse. Elevation of pH (>8.5) during coastal blooms becomes increasingly deleterious for plankton. Mixoplankton, which can be important bloom-formers, engage in both photoautotrophy and phagoheterotrophy; in theory, this activity could create a relatively stable pH environment for plankton growth. Using a systems biology modelling approach, we explored whether different mixoplankton functional groups could modulate the environmental pH compared to the extreme activities of phototrophic phytoplankton and heterotrophic zooplankton. Activities by most mixoplankton groups do not stabilize seawater pH. Through access to additional nutrient streams from internal recycling with phagotrophy, mixoplankton phototrophy is enhanced, elevating pH; this is especially so for constitutive and plastidic specialist non-constitutive mixoplankton. Mixoplankton blooms can exceed the size of phytoplankton blooms; the synergisms of mixoplankton physiology, accessing nutrition via phagotrophy as well as from inorganic sources, enhance or augment primary production rather than depressing it. Ocean acidification will thus enable larger coastal mixoplankton blooms to form before basification becomes detrimental. The dynamics of such bloom developments will depend on whether the mixoplankton are consuming heterotrophs and/or phototrophs and how the plankton community succession evolves.

Low rates of bacterivory enhances phototrophy and competitive advantage for mixoplankton growing in oligotrophic waters.

With climate change, oceans are becoming increasingly nutrient limited, favouring growth of prokaryotic picoplankton at the expense of the larger protist plankton whose growth support higher trophic levels. Constitutive mixoplankton (CM), microalgal plankton with innate phototrophic capability coupled with phagotrophy, graze on these picoplankton, indirectly exploiting the excellent resource acquisition abilities of the prokaryotes. However, feeding rates can be very low (e.g., a few bacteria d-1). For the first time, the significance of such low consumption rates has been quantified. We find that while prokaryote-carbon (C) supply to CM grown at non-limiting light was so low that it may appear insignificant (< 10%), contributions of nitrogen (N) and phosphorus (P) from ingestions of 1-12 prokaryotes d-1 were significant. Under limiting light, contributions of ingested C increased, also raising the contributions of N and P. The order of nutritional importance for CM growth from predation was P > N > C. Further, provision of N through internal recycling of ingested prey-N stimulates C-fixation through photosynthesis. Importantly, coupled photo-phago-mixoplanktonic activity improved CM resource affinities for both inorganic and prey-bound nutrients, enhancing the nutritional status and competitiveness of mixoplankton. With warming oceans, with increased prokaryote abundance, we expect CM to exhibit more phagotrophy.

Thermal Infrared Camera Imaging to Aid Necrotizing Soft Tissue Infections of the Genitalia Management.

OBJECTIVE: To determine if imaging with a thermal infrared camera might aid clinicians with diagnosis of equivocal necrotizing soft tissue infections of the genitalia (NSTIG) cases and help surgeons when determining appropriate surgical resection margins. MATERIALS/METHODS: For 12 months at a single tertiary academic hospital, sequential patients already undergoing exploration for acute scrotum had preoperative photography with an infrared camera (FLIR C5). We compared infrared and standard preoperative photography with operative reports and postoperative photography to investigate if infrared photography corresponded with operative findings in severe scrotal infections-specifically the viability of the skin and the ultimate surgical resection margins. RESULTS: A total of 16 patients were included. The pre-operative infrared photos directly correlated with resection margins in 13 of 16 (81%) patients. Notably, areas with a relatively lower (cooler) infrared intensity corresponded well to both visibly necrotic tissue when discrete and areas with large underlying fluid collections. Diffuse warm signal relative to surrounding skin correlated with cellulitis and viable skin. CONCLUSION: In this observational study, infrared photography corresponded well with physical exam and operative findings. There may be a role for augmented temperature photography in the diagnosis and triage of scrotal infections. More research with standardized temperature gating of infrared signal and controls with normal or nonacute scrotums are needed to elucidate the clinical utility for infrared photograph.

Mucus-Trap-Assisted Feeding Is a Common Strategy of the Small Mixoplanktonic Prorocentrum pervagatum and P. cordatum (Prorocentrales, Dinophyceae).

Prorocentrum comprises a diverse group of bloom-forming dinophytes with a worldwide distribution. Although photosynthetic, mixoplanktonic phagotrophy has also been described. Recently, the small P. cf. balticum was shown to use a remarkable feeding strategy by crafting globular mucus traps to capture and immobilize potential prey. Here we present evidence showing that two additional related species, the recently described P. pervagatum and the cosmopolitan bloom-forming P. cordatum, also produce large (80-120 µm) mucus traps supporting their mixoplanktonic activity. Prey are captured within the traps either through passive entanglement upon contact with the outside surface, or through active water movement created by rotating Prorocentrum cells eddying particles to the inside surface where trapped live prey cells became immobilized. Entrapment in mucus assisted deployment into the prey of a peduncle extruded from the apical area of the Prorocentrum cell. Phagotrophy by P. pervagatum supported faster growth compared to unfed controls and time series quantification of food vacuoles revealed ingestion rates of ca. 10-12 Teleaulax prey cells day-1. Model calculations show clear advantages of deploying a mucus trap for increasing prey encounter rates. This study demonstrates that the large size and immobilization properties of mucus traps successfully increase the availability of prey for small Prorocentrum species, whose peduncle feeding mode impedes consumption of actively moving prey, and that this strategy is common among certain clades of small planktonic Prorocentrum species.

Clinical Validation of an Adult-acquired Buried Penis Classification System Based on Standardized Evaluation of the Penis, Abdomen, and Scrotum.

OBJECTIVE: To clinically validate a previously developed adult-acquired buried penis (AABP) classification system that is based on a standardized preoperative physical examination that subtypes patients by their penile skin/escutcheon complex (P), abdominal pannus (A), and scrotal skin (S). METHODS: The Trauma and Urologic Reconstruction Network of Surgeons (TURNS) database was used to create an AABP cohort. Patients were retrospectively classified using the previously described PAS classification system. The frequency of subtypes, surgical methods utilized for AABP repair, and correlations between PAS classification and surgery subtypes were analyzed. RESULTS: The final cohort consisted of 101 patients from 10 institutions. Interrater reliability between two reviewers was excellent (κ = 0.95). The most common subtypes were P2c (contributory escutcheon+insufficient penile skin; 27%) and P2a (contributory escutcheon+sufficient penile skin; 21%) for penile subtypes, A0 (no pannus; 41%) and A1 (noncontributory pannus; 39%) for abdominal subtypes, and S0 (normal scrotal skin with preserved scrotal sulcus; 71%) for scrotal subtypes. AABP repair procedures included escutcheonectomy (n = 59, 55%), scrotoplasty (n = 51, 48%), split-thickness skin grafting (n = 50, 47%), penile skin excision (n = 47, 44%) and panniculectomy (n = 7, 7%). P, A, and S subtypes were strongly associated with specific AABP surgical techniques. CONCLUSION: The PAS classification schema adequately describes AABP heterogeneity, is reproducible among observers, and correlates well with AABP surgery types. Future work will focus on how PAS subtypes affect both surgical and patient-centered outcomes.

Management of Necrotizing Soft Tissue Infections (Fournier's Gangrene) and Surgical Reconstruction of Debridement Wound Defects.

In this article, the authors discuss the epidemiology, pathophysiology, and mechanism of spread of necrotizing soft-tissue infections of the genitalia, including classification schemas. The authors then discuss the acute clinical management of the disease, including suggestions for ways to improve surgical debridements (such that eventual reconstructions are simpler), ways to predict disease severity using laboratory, vital sign, and physical examination findings, and suggestions for initial antimicrobial treatments. Finally, reconstructive techniques and algorithms to ensure that the reconstructive goals of coverage, function, and cosmesis are met, are discussed, including the management of postoperative complications.

Nephrostomy Balloon and Sheath Suprapubic Tube Placement-A Minimally Invasive Approach to Large Caliber Suprapubic Tube Placement.

Suprapubic tubes (SPT) are a vital tool in the management of complex urologic voiding conditions. There are numerous methods of SPT placement, each with pros/cons: peel-away kits are easy to place, but often have small caliber SPTs, that is, 12 or 14 Fr, prone to kinking, that require serial upsizing to achieve the desired caliber; open SPT placements permit an initial large caliber SPT but are more invasive, particularly in obese patients. This video demonstrates a minimally invasive technique for SPT placement in patients with preserved urethral access to the bladder that safely allows for initial, precise placement of large caliber (>20F) catheters using the Nephromax nephrostomy balloon/sheath (NBS-SPT). Technique: A 6″ 17G Tuohy spinal needle is placed percutaneously 3 cm above the pubis (generally in the abdominal crease), 1-2 cm off midline towards the side the patient prefers to keep the drainage bag. The needle is angled to enter the bladder dome in the midline, which is visualized cystoscopically with a full bladder. The angling will allow the catheter to lie flat and decrease kinking. The stylette is removed and a stiff wire is advanced. A 2 cm horizontal skin incision is made. A 24 Fr NBS is advanced into the bladder under vision and inflated to 18 ATM. The balloon is then deflated/removed and the SPT is passed through the sheath into the bladder. Once inflated, the sheath removed and the SPT is secured to the skin. Study: A 10-year retrospective review of NBS-SPT placements at a single institution was performed, analyzing patient characteristics, surgical details, and surgical outcomes. NBS-SPT was attempted 65 times over the study period. The most common indications included acquired/congenital neurogenic bladder (48%) and urinary retention (25%). A simultaneous additional procedure (eg, cytolitholapaxy, bladder neck incision) was performed in 31% of NBS-SPTs. Median body mass index was 29.5 (interquartile range: 25-33.9) and 34% had prior abdominal procedures. Median operative time (NBS-SPT only) was 16 minutes (interquartile range: 14-20). All procedures were successful in placing a catheter 20F. Thirty-day Clavien I/II complication rate was 18% (hematuria n = 3; cellulitis n = 4; early SPT exchange for clogging n = 5); A Clavien IIIb complication occurred in one patient with hematuria requiring fulguration. First SPT exchange in clinic was successful in 95%, with 2 patients requiring replacement under anesthesia. NBS-SPT is a safe and efficient minimally invasive technique for initial, precise placement of large caliber SPT in patients with urethral bladder access.

Adult-Acquired Buried Penis Classification and Surgical Management.

In this article, the authors discuss the epidemiology, pathophysiology, and initial work-up for men with adult-acquired buried penis syndrome (AABP). Given the significant heterogeneity of AABP, a classification system is proposed which classifies the condition by the status of the abdominal pannus, the escutcheon, the penile skin and the scrotal skin, and their respective fascial attachments. Classification is achieved by a uniform assessment of anatomy using the proposed standardized preoperative photos. Various surgical strategies to repair AABP are proposed which, importantly, should be in line with the patient-centered goals and also differ widely with the condition.

Prospective Comparison of Opioid vs Nonopioid Pain Regimen After Ureteroscopy.

Objective: We wanted to evaluate two new treatment phases within our practice, including a nonopioid pathway, to determine the effect on opioid usage, health care utilization, and pain following ureteroscopy. Methods: Patients undergoing ureteroscopic lithotripsy were enrolled in a study utilizing text messaging to evaluate postoperative pain and opioid usage. Our historical postoperative pain regimen included #30 oxycodone. Patients in the N15 cohort were given improved counseling, preanesthesia acetaminophen, and #15 oxycodone. With further experience, narcotics were removed entirely from our postoperative care plan (N0) and replaced with a nonopioid multimodal regimen. Results: There were 61 and 58 patients in cohorts N15 and N0, respectively, with no difference in demographics, stone, or procedure details between each cohort. No difference in pain scores was detected between the N15 and N0 cohorts (p = 0.14). The median time to pain resolution was postoperative day (POD) 4 for cohort N15 and POD 3 for cohort N0 (p = 0.06). In the N0 cohort, nine patients required postoperative narcotics (15.5%; average of 2.4 pills/patient). There was no significant difference in emergency department visits, phone calls, or clinic visits (p = 0.17) between each cohort. Conclusions: Patients undergoing ureteroscopy have adequate postoperative pain control with a nonopioid treatment regimen, although some patients will still ultimately require narcotics.