Kidney Stones and Risk of Narcotic Use.

PURPOSE: The rise in opioid related deaths and addiction has been linked to physician prescribing. Opioids are commonly prescribed to patients with renal colic due to nephrolithiasis. The aim of this study was to describe the relationship between nephrolithiasis and opioid use in the United States. MATERIALS AND METHODS: Using the NHANES (National Health and Nutrition Examination Survey) we analyzed the relationship between a self-reported history of kidney stones and current opioid use in a nationally representative sample. RESULTS: Current opioid use was significantly greater among those who did vs did not report a history of kidney stones (10.9%, 95% CI 9.1-12.9 vs 6.1%, 95% CI 5.4-6.8). The prevalence of opioid use increased with the number of kidney stones passed, reaching 13.7% (95% CI 11.1-16.9) in subjects who had passed 2 or more stones (p <0.001). On multivariable logistic regression analysis adjusting for age, gender, smoking status, number of health care visits in the last year and comorbid conditions nephrolithiasis was independently associated with opioid based medication use (OR 1.27, 95% CI 1.07-1.49, p = 0.006). CONCLUSIONS: The association between a history of kidney stones and current narcotic use suggests that nephrolithiasis may be a risk factor for long-term opioid use. While this study is limited by the cross-sectional design and the absence of detailed stone histories, it adds to the evidence that altering pain management strategies may be beneficial in this population.

Rectal Injury During Penile Inversion Vaginoplasty.

OBJECTIVE: To evaluate the incidence, management, and outcomes of rectal injury (RI) and subsequent rectovaginal fistula (RVF) during gender-affirming vaginoplasty (GAV) at a high-volume transgender surgery center. METHODS: We performed a retrospective review of preoperative, intraoperative and post-operative findings of all patients with RI during GAV from January 2016 to September 2022. Descriptive statistics were calculated using Microsoft Excel. RESULTS: RI occurred in 9 of 1011 primary GAV and colorectal surgery (CRS) consulted in 5 cases, which included sigmoidoscopy with an air leak test in 4 and with temporary bowel diversion in 2. Of the 9, 6 proceeded with full-depth GAV, and 3 were converted to minimal-depth vaginoplasty. Two had bulbospongiosus muscle interposition and none had a concomitant urethral injury. 1/9 patients with RI developed a RVF which occurred in a patient with prior perineal surgery and no intraoperative sigmoidoscopy. Three (50%) with full-depth GAV developed vaginal stenosis postoperatively. CONCLUSIONS: RI during primary GAS in experienced hands is uncommon with an incidence of 0.89% in our series of 1011. Unusual tissue dissection planes were a risk factor. If injuries were identified intraoperatively, repaired with multilayer closure and evaluated by CRS, patients did well without the development of RVF despite completion of full-depth GAV. It is reasonable to complete the full-depth vagina, but patients should be advised of a significant risk of post-operative vaginal stenosis.

Ambulatory Bladder Cancer Care in the United States.

INTRODUCTION: Contemporary data on bladder cancer care in the United States are lacking. We used nationally representative data to characterize outpatient bladder cancer care in the U.S. and identify potential areas for quality improvement. METHODS: The NAMCS (National Ambulatory Medical Care Survey), conducted annually by the Centers for Disease Control and Prevention, is designed to generate weighted estimates of national ambulatory care practice patterns. We evaluated NAMCS data from 2001 to 2014 to characterize patient, physician and visit characteristics associated with a diagnosis of bladder cancer. RESULTS: During the 14-year study period there were 7,410,240 weighted visits to a urologist for a diagnosis of bladder cancer. The total number of urology visits for bladder cancer significantly increased during the study period (p=0.03). Overall 35% of patients with bladder cancer saw their urologist 6 or more times annually. Mean visit duration was 21.8 minutes. Mean age of patients with a bladder cancer diagnosis was 71.3 years. Men and women accounted for 8,106,756 and 3,052,690 visits, respectively (p <0.01). Medicare coverage represented the largest payer system (60.7%). Urologists provided smoking cessation counseling to only 21.2% of current smokers and nutrition counseling was provided for just 14.7% of all obese patients with bladder cancer. CONCLUSIONS: Bladder cancer visits account for more than half a million ambulatory urology visits annually. Routine lifestyle interventions such as smoking cessation and nutrition counseling should be implemented during urology visits to further improve the care of patients with bladder cancer.