A prospective randomized study evaluating the necessity of narcotics following ureteroscopy for urinary stone disease.

PURPOSE: To evaluate the efficacy of non-narcotic analgesics and preoperative counseling in managing postoperative pain and narcotic use following ureteroscopic laser lithotripsy (URS). METHODS: Adult patients at a single academic center undergoing URS for nephrourolithiasis were recruited. After informed consent, subjects were randomized into three groups: NARC-15 tablets oxycodone-acetaminophen 5/325 mg (A-OXY), 2. NSAID-15 tablets ibuprofen (IBU) 600 mg, 3. CNSL-15 tablets A-OXY, 15 tablets IBU, and preoperative counseling from the surgeon to avoid narcotic if possible. Patients who did not receive an intraoperative stent were excluded. At the time of stent removal subjects completed the Universal Stent Symptom Questionnaire (USSQ), and a pill count was performed. USSQ pain indices were the primary study endpoint. RESULTS: Of 115 patients enrolled, 104 met the primary endpoint and were included in the analysis. No significant differences were noted in patient demographic, clinical, or operative characteristics. No differences were noted in median USSQ pain indices. The CNSL group used a significantly lower median number of A-OXY pills compared to the NARC group (2.4 vs. 5.4, p = 0.001) and less IBU compared to the NSAID group (3.1 vs. 5.9, p = 0.008). No differences in median total pill count, office calls, medication requests, nor ED visits were noted. CONCLUSION: Our data suggest that patients can achieve equivalent postoperative analgesic satisfaction with non-narcotics compared to opiates following URS. Further, counseling patients on postoperative pain before surgery can reduce the total number of postoperative narcotic and non-narcotic medications taken. We suggest surgeons strongly consider omission of narcotic prescriptions following non-complicated URS.

Stent duration and increased pain in the hours after ureteral stent removal.

INTRODUCTION To assess the relationship between pain after ureteral stent removal and patient and procedural factors. MATERIALS AND METHODS: A validated survey designed to assess the relationship between quality of life and treatment decisions in kidney stone disease was randomly distributed to patients with a history of a ureteral stent in seven medical centers across North America participating in an endourology research collaborative between July 2016 and June 2018. The primary outcome was increased pain after ureteral stent removal. Statistical analyses were performed using Chi-square and multiple logistic regression. RESULTS: A total of 327 surveys were analyzed. Twenty seven percent of patients reported increased pain in the hours after ureteral stent removal. Patients with a stent ≤ 7 days were significantly more likely to experience pain after stent removal compared to those with a stent > 7 days (33.3% versus 22.8%, p = 0.04). Female gender (OR: 2.41, 95% CI: 1.42-4.10) was associated with increased pain after stent removal, while increasing age was inversely associated (OR: 0.52, 95% CI: 0.36-0.74). After adjustment, patients with a stent > 7 days were significantly less likely to report pain in the hours after removal (OR: 0.59, 95% CI: 0.35-0.99). CONCLUSIONS: Approximately one in four patients will experience increased pain after ureteral stent removal. Female patients, younger patients, and patients with a stent ≤ 7 days were more likely to experience an increase in pain immediately following stent removal. Understanding factors associated with post-stent removal pain may be helpful in counseling patients at high risk stent removal morbidity.

Is metformin use associated with changes in urinary parameters in stone formers?

INTRODUCTION: Diabetes mellitus (DM) is associated with an increased risk of nephrolithiasis and is often treated with metformin. The relationship between metformin and nephrolithiasis formation remains unclear, as studies have demonstrated conflicting results. METHODS: We conducted a cross-sectional analysis of stone-forming patients at our stone clinic prior to the initiation of stone-directed medical management. Patients were grouped based on diabetic status and diabetic medication regimen. Outcomes evaluated were 24-hour urinary parameters and specimen stone type using univariate Kruskal-Wallis and Chi-squared analyses. Multivariate analyses controlling for metabolic syndrome components and HbA1c were performed. RESULTS: Data were available for 505 patients, of whom 147 were diabetic and 358 were not. On multivariate analyses controlling for HbA1c and other comorbidities, diabetic patients on metformin still had worse urinary parameters, including urine pH, than non-diabetic patients (pH=-0.33, -0.37, p<0.05). Patients with DM on metformin did not exhibit significant differences in 24-hour urine findings compared to patients with DM not on metformin (p>0.05 for all urinary parameters). CONCLUSIONS: Stone-forming patients with DM on metformin were associated with urinary abnormalities similar to those not on metformin. Cohort studies comparing urinary parameters of patients prospectively started on metformin are necessary to further elucidate metformin's role, if any, in combatting nephrolithiasis.

Heterogeneity in stone culture protocols and endourologist practice patterns: a multi-institutional survey.

Kidney stone cultures can be beneficial in identifying bacteria not detected in urine, yet how stone cultures are performed among endourologists, under what conditions, and by what laboratory methods remain largely unknown. Stone cultures are not addressed by current clinical guidelines. A comprehensive REDCap electronic survey sought responses from directed (n = 20) and listserv elicited (n = 108) endourologists specializing in kidney stone disease. Questions included which clinical scenarios prompt a stone culture order, how results influence post-operative antibiotics, and what microbiology lab protocols exist at each institution with respect to processing and resulting stone cultures. Logistic regression statistical analysis determined what factors were associated with performing stone cultures. Of 128 unique responses, 11% identified as female and the mean years of practicing was 16 (range 1-46). A specific 'stone culture' order was available to only 50% (64/128) of those surveyed, while 32% (41/128) reported culturing stone by placing a urine culture order. The duration of antibiotics given for a positive stone culture varied, with 4-7 days (46%) and 8-14 days (21%) the most reported. More years in practice was associated with fewer stone cultures ordered, while higher annual volume of percutaneous nephrolithotomy was associated with ordering more stone cultures (p < 0.01). Endourologists have differing practice patterns with respect to ordering stone cultures and utilizing the results to guide post-operative antibiotics. With inconsistent microbiology lab stone culture protocols across multiple institutions, more uniform processing is needed for future studies to assess the clinical benefit of stone cultures and direct future guidelines.

Factors Affecting Patient Radiation Exposure During Prone and Supine Percutaneous Nephrolithotomy.

Purpose: Radiation exposure from fluoroscopy poses risks to patients and surgeons. Percutaneous nephrolithotomy (PCNL) has traditionally required fluoroscopy, however, the use of ultrasound (US) has decreased radiation exposure. US guidance in supine PCNL (S-PCNL) may further reduce radiation exposure. In this study, we investigate patient and operative factors affecting fluoroscopy time (second), total radiation dose (mGy), and effective dose (ED, mSv) in patients undergoing US-guided S-PCNL or prone PCNL (P-PCNL). Methods: We performed a retrospective study of patients undergoing US-guided PCNL in prone and supine positions. Patients with multiple access tracts, pre-existing renal access, or fluoroscopic renal access were excluded. Patient demographic and radiologic and operative data were collected, and compared between the two groups. Results: Ninety-nine patients were included: 45 P-PCNL and 54 S-PCNL. There were no significant demographic differences between the two groups. Operative time, access location, tract length, and total radiation dose (mGy) also did not differ. S-PCNL was associated with lower ED (2.92 ± 0.32 mSv vs 5.3 ± 0.7 mSv, p = 0.0014) despite increased fluoroscopy time (86.32 ± 7.7 seconds vs 51.00 ± 5.1 seconds, p = 0.004), and was more likely a mini-PCNL (35.2% vs 15.9%, p = 0.032). In multivariate analysis, S-PCNL remained associated with reduced ED compared with P-PCNL (p = 0.002), whereas body mass index (p < 0.001) and staghorn calculi (p < 0.001) were independently associated with increased ED. Conclusions: We demonstrated that ED in US-guided PCNL is increased in the prone position compared with supine position, and in overweight patients regardless of position. US-guided S-PCNL may decrease radiation exposure to patients and surgeons compared with US-guided P-PCNL.

Novel treatment of upper tract urothelial carcinoma in situ with docetaxel in BCG refractory patients.

INTRODUCTION: Patients with upper-tract carcinoma in situ (UT-CIS) that have failed treatment with BCG are recommended for radical nephroureterectomy (RNU). We describe a cohort of patients with BCG-refractory UT-CIS that were treated with docetaxel, a novel agent in the approach to topical therapy. METHODS: Patients with pathologically proven UT-CIS from 2012 to 2020 with an imperative indication for organ preservation and history of BCG-refractory disease were included. Each patient underwent ureteroscopy with biopsy and selective cytology pre- and postinduction, and after each maintenance course. Complete response (CR) was defined as the absence of visualized lesions on ureteroscopy, negative selective cytology, and absence of clinical progression. No response (NR) was defined as persistence of lesions after induction or absence of visualized lesions with persistently positive cytology. RESULTS: Seven patients and 10 renal units were treated. Six of the 10 renal units had initial CR (60%). Three patients with NR went on to have RNU, one of which subsequently died due to cancer-specific mortality. One patient with bilateral disease had NR in 10 renal unit and cure in the other. This patient subsequently developed recurrence in his remaining renal unit. A second patient had CR in both kidneys for 6 years, but 1 year after finishing maintenance regimen developed HG disease in 1 ureter. Average follow-up was 33 months. CONCLUSION: This study demonstrates efficacy of docetaxel as a treatment option for patients with UT-CIS with a contraindication to RNU after failing BCG. Response rates of 60% appear to be similar to those of BCG-refractory bladder CIS.

Long-Term Outcomes of Laser Incision and Triamcinolone Injection for the Management of Ureteroenteric Anastomotic Strictures.

Purpose: Benign ureteroenteric anastomotic stricture (UEAS) is a common postoperative complication after urinary diversion with an incidence of 3%-10%. Our objective is to report long-term follow-up of our technique for endoscopically managing UEAS after cystectomy. Materials and Methods: Patients with endoscopically managed benign UEAS after cystectomy were included. Intervention entailed anetegrade flexible ureteroscopy with biopsy followed by laser incision of the stricture and of periureteral and peri-ileal tissues 1 cm below and 1 cm above the stricture into fat. Triamcinolone injection was then performed, followed by balloon dilation of the incised area to 24F. Parallel Double-J ureteral stents or upside down nephrostomy tubes were placed for 6 weeks. CT scans were obtained at 3 months and 1 year after surgery, and renal ultrasound at 6 and 9 months, and then annually. Results: Twenty-one patients, and a total of 24 UEAS were treated. Urinary diversion included ileal conduit (n = 12), neobladder (n = 7), and Indiana pouch (n = 2). Twenty out of 24 strictures had no recurrence, including three patients who had bilateral disease, yielding an overall success rate of 83.3%. The remaining three patients with recurrence had evidence of stricture within 3 months. Follow-up ranged from 8 to 102 months, with a median of 30 months. Conclusions: Patients treated endoscopically for UEAS have been shown to have acceptable immediate success with less morbidity when compared with ureteral reimplantation. Our technique of laser incision, triamcinolone injection, balloon dilation, and temporary stent placement has a success rate of over 80% and is unique in that long-term data confirms the durability of this endoscopic procedure.

Uretero-Enteric Anastomotic Stricture Following Radical Cystectomy: A Comparison of Open, Robotic Extracorporeal, and Robotic Intracorporeal Approaches.

OBJECTIVES: To compare the incidence of benign uretero-enteric anastomotic strictures between open cystectomy, robotic cystectomy with extracorporeal urinary diversion, and robotic cystectomy with intracorporeal urinary diversion. The effect of surgeon learning curve on stricture incidence following intracorporeal diversion was investigated as a secondary outcome. PATIENTS AND METHODS: Patients who underwent radical cystectomy at an academic hospital between 2011 and 2018 were retrospectively reviewed. The primary outcome, incidence of anastomotic stricture over time, was assessed by a multivariable Cox proportional hazards regression. A Cox regression model adjusting for sequential case number in a surgeon's experience was used to assess intracorporeal learning curve. RESULTS: Nine hundred sixty-eight patients were included: 279 open, 382 robotic extracorporeal, and 307 robotic intracorporeal. Benign stricture incidence was 11.3% overall: 26 (9.3%) after open, 43 (11.3%) after robotic extracorporeal, and 40 (13.0%) after robotic intracorporeal. An intracorporeal approach was associated with anastomotic stricture on multivariable analysis (HR 1.66; P = .05). After 75 intracorporeal cases, stricture incidence declined from 17.5% to 4.9%. Higher sequential case volume was independently associated with reduced stricture incidence (Hazard Ratio per 10 cases: 0.90; P = .02). CONCLUSION: An intracorporeal approach to urinary reconstruction following robotic radical cystectomy was associated with an increased risk of benign uretero-enteric anastomotic stricture. In surgeons' early experience with intracorporeal diversion the difference in stricture incidence was more pronounced compared to alternative approaches; however, increased intracorporeal case volume was associated with a decline in stricture incidence leading to a modest difference between the 3 surgical approaches overall.

Reduction in Opioid Prescribing Using a Postoperative Pain Management Protocol following Scrotal and Subinguinal Surgery.

INTRODUCTION: Excess prescribing of opioid pain medication increases medical costs and the potential for abuse by patients and others. We sought to improve our understanding of postoperative pain and opioid use after scrotal and subinguinal urological surgery to develop a protocol for pain management. METHODS: We retrospectively analyzed opioid prescribing and usage in 20 patients undergoing scrotal or subinguinal surgery. Collected data were used to develop a standardized postoperative protocol. This protocol included enhanced pain management education and limiting outpatient opioid prescriptions. Outcomes analysis was then performed for 60 consecutive patients via questionnaire. Statistical analysis was performed using the Wilcoxon rank sum test and ANOVA. Linear regression was performed comparing age and narcotic use. RESULTS: Comparison of preprotocol and postprotocol implementation opioid prescriptions and consumption showed a statistically significant decrease in the number of tablets prescribed but no difference in opioid usage. Preprotocol and postprotocol opioid prescription usage was 20 and 10 tablets, respectively, while median usage was 3.5 and 3 tablets, respectively. CONCLUSIONS: Evaluation of postoperative pain management revealed excessive prescribing of opioid medications compared to actual usage. Our protocol resulted in a significant decrease in opioid prescribing without compromising management of postoperative pain. Adjunct treatments for pain, including scrotal support, ice packs, elevation and nonsteroidal anti-inflammatory drugs, may improve postoperative pain control without increasing opioid usage. The combination of enhanced patient education and reduced opioid prescribing may result in decreased opioid use, opioid abuse and medication costs.

Robotic Salvage Pyeloplasty With Buccal Mucosal Onlay Graft: Video Demonstration of Technique and Outcomes.

OBJECTIVE: To present the use of buccal mucosal graft (BMG) in a salvage robotic laparoscopic pyeloplasty as an alternative in the management of a recurrent ureteropelvic junction (UPJ) obstruction. METHODS: We present 2 patients with a recurrent UPJ obstruction who had previously undergone 2 prior open or robotic pyleoplasties, followed by endoscopic management. Preoperative imaging was obtained before surgical repair. The UPJ was incised and the incision extended to reveal margins of a healthy normal-caliber ureteral tissue. Single BMGs were harvested from the inner cheek of each patient. The grafts were of sufficient caliber and size to cover the entire defect as an onlay graft, and to maintain a tension-free and watertight anastomosis. RESULTS: The operative time was between 188 and 284 minutes. The estimated blood loss was 25-50 mL. The hospital stay was 2 days for each patient. Foley catheters were removed before discharge and the Jackson-Pratt drains were removed in the immediate postoperative period. The ureteral stents were removed at 6 and 9 weeks, with retrograde pyelograms confirming patency at the UPJ. Lasix renograms were obtained after 4 months and either demonstrated a resolution or were equivocal for obstruction, with a preservation of renal function. Both patients have been without complication since the stent removal. CONCLUSION: Robotic pyeloplasty with BMG is an alternative in the management of recurrent UPJ obstructions. Short-term follow-up has demonstrated that it is an effective and attractive approach compared with more extensive and invasive surgeries such as a renal autotransplant and an ileal ureter.