Erector spinae plane blocks for analgesia after percutaneous nephrolithotomy A pathway to reduce opioids.

INTRODUCTION: Despite its minimally invasive nature, percutaneous nephrolithotomy (PCNL ) may be associated with significant pain. Challenges in pain control may prevent timely discharge (and expose patients to adverse effects of opioid use). We sought to evaluate whether our patients who underwent erector spinae plane (ESP) regional blocks experienced improved postoperative pain control and decreased opioid use after PCNL (compared with those who did not receive blocks). METHODS: We retrospectively reviewed consecutive PCNL cases on patients admitted for greater than 24 hours without pre-existing opioid regimens for chronic pain. Cases were completed by a single high-volume surgeon. Patients who accepted an ESP block were compared to those who did not receive a block. Patients received either a single injection or a disposable pump delivering intermittent boluses of ropivacaine 0.2%. Demographic and perioperative data were analyzed. The primary outcomes were opioid use measured in morphine milligram equivalent (MME ) and patient-reported pain scores during the first 24 hours of hospitalization. RESULTS: From March 2019 to August 2021, 44 patients were identified who met criteria - 28 of whom received an ESP block (including 14 continuous blocks). The patients who received blocks had significantly decreased opioid use (18.3 vs. 81.3 MME, p=0.004) and a longer mean time to first non-zero pain score (p=0.004). Continuous blocks had similar opioid use to single shot blocks (21.0 vs. 15.6 MME, p=0.952). CONCLUSIONS: ESP regional blocks appear to offer an effective adjunct method for pain control after PCNL and may reduce post-PCNL opioid use while maintaining adequate patient analgesia.

Understanding Causes for Admission in Planned Ambulatory Percutaneous Nephrolithotomy.

Introduction: For treatment of nephrolithiasis, ambulatory percutaneous nephrolithotomy (aPCNL) is growing in popularity for select patients. The aim of this study was to investigate the safety and efficacy of a set of aPCNL selection criteria as well as search for predictors of failed aPCNL resulting in inpatient admission. Materials and Methods: We reviewed all percutaneous nephrolithotomy (PCNL) patients from 2016 to 2020. A total of 175 met selection criteria for aPCNL and were included. Primary outcome was safety and efficacy, and secondary outcome was to identify predictors of inpatient stay. Demographic and perioperative data were analyzed with both descriptive and inferential statistics. Results: In total, between 2016 and 2020, 552 patients underwent PCNL, with 175 of them meeting criteria for aPCNL. One hundred thirty-four of the 175 (76.6%) of these patients were discharged the same day as the surgery and 41 patients were admitted. On univariate analysis, patients who required upper pole access or multiple accesses (p = 0.038) American Society of Anesthesiologists >2 (p = 0.005), or postoperative nephrostomy (PCN) tube (p < 0.001) were more likely to be admitted after surgery. On multivariate analysis, only postoperative PCN was significantly associated with admission (p = 0.015). Regarding reasons for unsuccessful aPCNL, 19.5% of admissions were attributed to intraoperative complications, 7% to social causes, 12.2% to postoperative complications, 14.6% to uncontrolled pain, and 34.1% to unexpected intraoperative procedures. Conclusions: aPCNL using selection criteria is safe and effective, with postoperative PCN predicting the possible necessity for conversion to inpatient admission. Furthermore, our study provides a practical algorithm for those opting to provide aPCNL to patients.

Unplanned Open Conversion During Radical or Partial Nephrectomy: Comparing Outcomes and Trends.

OBJECTIVES: To compare perioperative outcomes between open conversion and planned open surgical approach and to investigate trends. MATERIALS AND METHODS: The National Cancer Database (NCDB) was queried for cT1 and cT2 RCC treated by radical (RN) or partial (PN) nephrectomy between 2010 and 2016. We retrospectively analyzed patient demographics, clinical tumor characteristics, and perioperative outcomes between unplanned open conversion and planned open approaches for RN and PN. RESULTS: In total, 152,919 patients underwent RN or PN for cT1 or cT2 RCC over the 7-year span. The rate of unplanned open conversion from MIS was 3.9% overall, remaining lowest for cT1 PN (2.7%) and highest for cT2 RN (5.9%). Cases of open conversion tended to have higher rate of upstaged disease. When comparing open conversion to a planned open case, there was no difference in the length of post-operative hospitalization. On logistic regression, unplanned open conversion from MIS was associated with higher odds of positive margin for RN but not for PN. Increased odds of 30-day's readmission were associated with unplanned open conversion from MIS in the setting of cT1 PN only. CONCLUSION: When compared to a planned open approach, conversion to open from MIS does not affect length of hospital stay but is associated with higher odds of positive surgical margins for RN and higher odds of 30-day's readmission for cT1 PN. Advanced pathologic stage is associated with an open conversion, likely relating to increased tumor complexity. These findings should be considered preoperatively when determining the best surgical approach.

Diagnosis, management, and follow-up of upper tract urothelial carcinoma: an interdisciplinary collaboration between urology and radiology.

Upper tract urothelial carcinoma (UTUC) is a common and lethal malignancy. Patients diagnosed with this illness often face invasive workups, morbid therapies, and prolonged post-operative surveillance. UTUC represents approximately 5-10% of urothelial malignancies in the United States and affect 4600-7800 new patients annually. Various environmental exposures as well as smoking have been implicated in the development of UTUC. The diagnosis and workup of UTUC relies on heavily on imaging studies, a close working relationship between Urologists and Radiologists, and invasive procedures such as ureteroscopy. Treatments range from renal-sparing endoscopic surgery to radical extirpative surgery depending on the specific clinical situation. Follow-up is crucial as UTUC has a high recurrence rate. Here we review the epidemiology, diagnosis, management strategies, and follow-up of UTUC from an interdisciplinary perspective.

Observation of a strong-coupling effect on electron-ion collisions in ultracold plasmas.

Ultracold plasmas (UCPs) provide a well-controlled system for studying multiple aspects in plasma physics that include collisions and strong-coupling effects. By applying a short electric field pulse to an UCP, a plasma electron center-of-mass oscillation can be initiated. For accessible parameter ranges, the damping rate of this oscillation is determined by the electron-ion collision rate. We performed measurements of the oscillation damping rate with such parameters and compared the measured rates to both a molecular dynamics (MD) simulation that includes strong-coupling effects and a Monte Carlo binary collision simulation designed to predict the damping rate including only weak-coupling considerations. We found agreement between the experimentally measured damping rate and the MD result. This agreement did require including the influence of a previously unreported UCP heating mechanism whereby the presence of a dc electric field during ionization increased the electron temperature, but estimations and simulations indicate that such a heating mechanism should be present for our parameters. The measured damping rate at our coldest electron temperature conditions was much faster than the weak-coupling prediction obtained from the Monte Carlo binary collision simulation, which indicates the presence of a significant strong-coupling influence. The density averaged electron strong-coupling parameter Γ measured at our coldest electron temperature conditions was 0.35(8).