Decreased Opioid Prescription With Low Pain Scores After Urethroplasty: Using a Simplified, Multimodal, Opioid Minimization Pain Protocol.

OBJECTIVE: To implement a simplified, opioid-minimized, multimodal pain management (MPM) protocol and assess its effectiveness of reducing opioid dispersion while maintaining low postoperative complications, patient-reported pain, and patient-reported interference with quality of life (QOL) for men undergoing urethroplasty. METHODS: Ninety-five men at a single academic center from October 2020 to October 2023 received a urethroplasty. We retrospectively reviewed the prior standard pain management (SPM) cohort before August 2021, then prospectively studied the MPM cohort after August 2021. For the SPM cohort, we collected postoperative day (POD) 1 pain scores from our Electronic Medical Record (EMR). For the MPM cohort, we obtained a validated pain and QOL assessment in the early postoperative period. The SPM cohort's POD 1 pain scores were compared with the MPM cohort's POD 2 pain scores. Opioid dispensation records were queried from the Prescription Monitoring Program. RESULTS: Seventy-five morphine milligram equivalent fewer opioids in the MPM cohort were prescribed than the SPM cohort (0 (interquartile range [IQR]: 0-0) vs 75 (IQR:0-150), P < .001, respectively). Patients with opioid discharge prescriptions fell from 50% in the SPM cohort to 11% in the MPM cohort (P < .001). Early postoperative pain scores remained low and showed no significant difference between the cohorts. Pain's interference with QOL measures remained low. Complications were rare across both cohorts. CONCLUSION: This simplified, multimodal analgesia protocol effectively decreases postoperative pain and opioid dispersion without affecting QOL outcomes after urethroplasty. This pain regimen can be easily adopted to decrease the use of postoperative opioids in men undergoing urethroplasty.

Current devices, outcomes, and pain management considerations in penile implant surgery: an updated review of the literature.

Penile prosthesis surgery is a definitive treatment for erectile dysfunction (ED). The two categories of penile prosthesis are endorsed by professional guidelines, inflatable penile prosthesis (IPP) and malleable penile prosthesis (MPP). Each modality of penile prosthesis offers distinct advantages and incorporates specific design features, allowing for personalized device selection that aligns with individual needs and preferences. While the overall complication rate of penile implant surgery remains low, surgeons should maintain a high index of suspicion for complications in the perioperative time period. Multimodal analgesic regimens including nerve blocks and narcotic-free pathways should be administered to manage perioperative pain. Finally, the high patient satisfaction after penile prosthesis surgery underscores the success of this ED treatment option.

Decreased Opioid Use and Equivalent Pain Score Outcomes After Robotic Urologic Surgery Using a Simplified Opioid Minimization Protocol: A Safety-Net Hospital Experience.

INTRODUCTION: We aimed to implement a simplified opioid minimization (OM) protocol after robotic urologic surgery in a safety-net hospital to decrease opioid consumption without compromising patient-reported pain or satisfaction. METHODS: Robotic urologic surgery was performed in 103 consecutive patients at a safety-net hospital. An opioid control (OC) cohort was established from January to May 2021, and the OM protocol was implemented from June to October 2021. On postoperative day (POD) 2 and POD7, a validated survey was used to assess pain and satisfaction. Opioid dispensation records were queried from the Prescription Monitoring Program. Outcomes were compared by univariate methods. RESULTS: There were no demographic differences between the OM (n = 45) and OC (n = 35) cohorts. Total opioids received within 30 days of surgery decreased by 68% in the OM vs OC cohort (median [IQR] 32.5 [7.5-65] vs 100 [30-173] morphine milligram equivalents, P < .001). The median amount of opioids prescribed at discharge for the OM cohort was 0 (IQR:0-0) vs 75 morphine milligram equivalents (IQR:0-112.5) for the OC cohort (P < .001). Pain severity did not differ between cohorts on POD2 (median [IQR]: OM=3/10 [2-5], OC=3.5/10 [2-6]; P = .5) or POD7 (median [IQR]: OM=2/10 [0-3], OC=1/10 [0-3]; P = .8), and POD7 satisfaction with pain management remained high for both cohorts (P = .8). CONCLUSIONS: Our simplified OM protocol decreased total opioid use after robotic urologic surgery by 68% without compromising pain or satisfaction.

Impaired robotic surgical visualization: archaic issues in a modern operating room.

While robotic-assisted surgery (RAS) has been revolutionizing surgical procedures, it has various areas needing improvement, specifically in the visualization sector. Suboptimal vision due to lens occlusions has been a topic of concern in laparoscopic surgery but has not received much attention in robotic surgery. This study is one of the first to explore and quantify the degree of disruption encountered due to poor robotic visualization at a major academic center. In case observations across 28 RAS procedures in various specialties, any lens occlusions or "debris" events that appeared on the monitor displays and clinicians' reactions, the cause, and the location across the monitor for these events were recorded. Data were then assessed for any trends using analysis as described below. From around 44.33 h of RAS observation time, 163 debris events were recorded. 52.53% of case observation time was spent under a compromised visual field. In a subset of 15 cases, about 2.24% of the average observation time was spent cleaning the lens. Additionally, cautery was found to be the primary cause of lens occlusions and little variation was found within the spread of the debris across the monitor display. This study illustrates that in 6 (21.43%) of the cases, 90% of the observation time was spent under compromised visualization while only 2 (7.14%) of the cases had no debris or cleaning events. Additionally, we observed that cleaning the lens can be troublesome during the procedure, interrupting the operating room flow.

Effect of Low Positive End of Treatment Viral Load with Direct-Acting Antiviral Therapy on Sustained Virologic Response.

Background: Direct-acting antivirals (DAAs) are highly effective treatments against hepatitis C virus (HCV), with sustained virologic response (SVR) rates of 93-100% against all genotypes. In most patients, viral load (VL) becomes undetectable four weeks into treatment, but rarely a low positive VL may be observed at the end of treatment (EOT). This study was conducted to determine the effect of low positive EOT VLs with DAA therapies on SVR at 12 and 24 weeks. Methods: A retrospective chart review was conducted from January 2014 to December 2018 on 1256 HCV patients of all genotypes (1-6) who had received DAA therapy at two large hepatology referral centers. Baseline demographic data, along with VL at week four, EOT, and SVR12/24 time points were collected for patients that had positive EOT VL. Treatment outcome for any patient with positive EOT VL was noted. Results: Eight out of 1256 patients treated with varying DAA therapies were observed to have low positive EOT VLs ranging from <15 to 235 IU/mL. One patient had a negative EOT VL, but 23 IU/mL at week four after EOT. All eight patients who had low positive EOT VLs and one patient who had a low positive VL at four weeks after EOT achieved SVR at weeks 12 and 24. One of the eight patients had cirrhosis. The majority of patients were genotype 1a. Conclusion: In the DAA treatment era, low levels of detectable HCV RNA at EOT does not predict treatment failure.