Opioid prescription usage and disposal after provider education and SMS-based parent education.

INTRODUCTION: Adequate pain control after outpatient pediatric urologic surgery is important for both providers and caregivers; however, opioid pain medications are often prescribed in excess of utilization. The resultant excess opioid medication has potential to be diverted or misused. While families are instructed to dispose of leftover opioids, a significant proportion may not dispose of leftover medication. We performed a quality improvement (QI) initiative within a tertiary academic care center to examine opioid excess, opioid disposal, and whether a two-component QI intervention of provider education and family education via automated SMS messages on opioid disposal could improve excess opioid prescribing and leftover opioid disposal. MATERIALS AND METHODS: Prospective parent surveys were performed on a baseline cohort of 73 patients undergoing outpatient pediatric urologic surgery between July 27 and September 4, 2020. Based on baseline data, a two-component quality improvement initiative was implemented. The first component was non-binding surgeon education regarding opioid prescribing versus opioid utilization. The second component was initiation of automated SMS messages to families after surgery with information on expected postoperative course and hyperlinked instructions for opioid disposal with GPS search for opioid disposal sites nearby. We then repeated the survey for a second cohort of patients between September 14 and October 29, 2021, including additional questions regarding SMS message utility. RESULTS: Of 73 patients in the baseline group, 46% were prescribed opioids (Summary Table). Of patients prescribed opioids, a median of 3 doses were used and 96% had leftover opioid medication. Seventeen percent of parents in the baseline group disposed of unused opioids prior to survey completion (1-4 weeks postop). After the intervention, 19 of 74 (26%) patients were prescribed opioids. In the group that received opioids, a median of 2 doses were used and 63% reported disposing of opioids. Ninety-six percent of parents reported satisfaction with SMS messages. DISCUSSION: Many competing priorities exist for surgical providers and parents of children undergoing outpatient pediatric urologic surgery. A passive program that delivers just-in-time information in the postoperative period has high utility for both parents and providers. CONCLUSIONS: Automated SMS messages and provider education about opioid utilization are associated with decreased excess opioid after outpatient pediatric urologic surgery and improved opioid disposal rates by parents. These interventions are easily implemented without significant manpower and should be considered by organizations interested in decreasing excess community opioids after outpatient pediatric urologic surgery.

Is chest imaging needed as part of pT1a renal cell carcinoma surveillance after surgical resection?

INTRODUCTION: Following surgical excision of pT1a renal cell carcinoma (RCC), 2% to 5% will recur, with 50% to 60% being lung metastases. The ideal surveillance strategy to identify recurrences is unclear. Guidelines are mixed, with NCCN and AUA recommending surveillance via chest x-ray (CXR) at least annually for 5 years, while EAU guidelines do not specifically recommend the use of CXR. In an effort to clarify the utility of surveillance CXR, we retrospectively evaluated pT1a patients following surgical treatment at a single institution. METHODS: We performed retrospective analysis of unique patients who underwent surgical excision of pT1 RCC between January 2000 and January 2020. In addition to demographic information, we collected RCC pathology, recurrence details, and most recent chest imaging. We excluded non-RCC pathology, and patients with pulmonary nodules on baseline imaging. RESULTS: We identified 463 unique patients (mean age 58.3 years, range 23-87) that underwent surgical excision of pT1a RCC with mean follow-up of 47.6 months (range 1-201). On the most recent pulmonary surveillance imaging, 72.4% (335/463) had CXR while 27.6% (128/463) had chest CT performed. Regardless of modality, pulmonary recurrence was not detected on any surveillance imaging (0/463). CONCLUSION: In patients without baseline preoperative lung pathology, we found that there is questionable clinical value in surveillance for pulmonary recurrence after resection of pT1a RCC.

Limited success with clostridium collagenase histolyticum following FDA approval for the treatment of Peyronie's disease.

Collagenase clostridium histolyticum (CCH) was approved for the treatment of Peyronie's disease (PD) in December of 2013. Recently, further research has supported its use. The aim of this study was to objectively evaluate the effects of CCH on penile curvature associated with Peyronie's disease at our high volume institution. Since the approval of CCH for PD, 45 men have undergone between 1 and 4 treatment cycles (mean 3.13, standard deviation (SD) = 0.87) at our institution. Primary as well as secondary curvature, if any, was measured before beginning therapy and after each cycle of therapy. The degree of curvature was compared. We also questioned these men about their subjective experience with CCH. The mean age of this cohort was 55.7 years (range 35-70). The mean primary curvature was 53.6° (SD = 16.5). Post-treatment mean primary curvature was 48.2° (SD = 19.5), p = 0.10. Secondary curvature was reduced from 24.1° (SD = 11.3) to 20.4° (SD = 11.5) before and after treatment with CCH, respectively, p = 0.27. There were two tunical ruptures in this series after which both ceased therapy with CCH. Additionally, 37/45 patients in this series expressed some degree of dissatisfaction in their post-therapy visits with most of these men stating that they did not notice a change in their curvature. CCH remains an option for the treatment of PD. Predictors of success, however, are lacking. Our experience showed a less-robust response to CCH than previous studies and underscores the need for effective and clear patient counseling prior to the initiation of therapy with CCH for PD in the post-FDA-approval setting.

Neurilemoma of the posterior tibial nerve and tarsal tunnel syndrome.

Tarsal tunnel syndrome is defined as a compressive neuropathy of the posterior tibial nerve in the tarsal canal. A neurilemoma is an uncommon, benign, encapsulated neoplasm derived from Schwann cells. We present a case of tarsal tunnel syndrome caused by this rare space-occupying lesion.

Epidermal inclusion cyst in the foot of a Vietnam Veteran.

Epidermal inclusion cysts are soft-tissue lesions that result from traumatic implantation of epidermal cells into the dermis. A case report is presented involving a large recurrent plantar inclusion cyst secondary to trauma sustained in the Vietnam War. The patient reported that the initiating trauma was the result of stepping on a punji stake in Vietnam. Punji stakes, sharpened spikes typically made of bamboo and dipped in poison or excrement, were used by the Vietnamese soldiers to wound enemy soldiers. Careful excision of the lesion is imperative to prevent recurrence.