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Early Surgical Intervention for Symptomatic Renal and Ureteral Stones is Associated With Reduced Narcotic Requirement Relative to Trial of Passage

Published:September 29, 2020DOI:https://doi.org/10.1016/j.urology.2020.08.063

      Objectives

      To evaluate if trial of passage (TOP) or initial surgical intervention resulted in less narcotic analgesia utilization in patients with acute renal colic due to stone disease.

      Methods

      We retrospectively evaluated 135 patients with acute renal colic due to nephroureterolithiasis managed by a single surgeon. Patients were standardly offered TOP or surgical intervention with ureteroscopy (URS). A subset of patients were stented with delayed URS due to presence of infection, pain, or a nonaccommodating ureter. Our standard practice is narcotic-free URS, prescribing a stent cocktail including non-steroidal anti-inflammatories. We compared rates of narcotic prescription over the entire treatment course for patients electing TOP vs surgery (primary or delayed URS). We secondarily analyzed rates of surgical intervention among initial TOP.

      Results

      We included 135 patients, with 69 (51.1%) TOP as initial treatment, 39 (28.9%) stent with delayed URS, and 27 (20.0%) primary URS. Thirty-nine (56.5%) TOP patients underwent URS at a median time of 18 days (IQR 6-31 days) from diagnosis. More TOP patients required a narcotic prescription (60.9% vs 35.9% vs 33.3%, respectively; P = .010) compared to patients undergoing initial stent or URS. However, when an opioid prescription was provided, the total morphine milligram equivalents prescribed among each group was not statistically significant.

      Conclusion

      Patients electing initial treatment with TOP for renal colic due to stone disease were more likely to require narcotic prescriptions than patients electing initial surgical intervention.
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      References

      1. Centers for Disease Control and Prevention. Vital signs: opioid prescribing: where you live matters, 2017. Available at: https://www.cdc.gov/vitalsigns/opioids/index.html (Accessed November 12, 2019)

        • Pasricha SV
        • Tadrous M
        • Khuu W
        • et al.
        Clinical indications associated with opioid initiation for pain management in Ontario, Canada: a population-based cohort study.
        Pain. 2018; 159: 1562-1568
      2. Centers for Disease Control and Prevention. Vital signs: opioid overdoses treated in emergency departments, 2018. Available at: https://www.cdc.gov/vitalsigns/opioids/index.html (Accessed August 8, 2019)

      3. Centers for Disease Control and Prevention. Policy impact: prescription painkiller overdoses, 2011. Available at:https://www.cdc.gov/drugoverdose/pdf/PolicyImpact-PrescriptionPainkillerOD-a.pdf (Accessed November 12, 2019)

        • Chen Z
        • Prosperi M
        • Bird VY
        Prevalence of kidney stones in the USA: the national health and nutrition evaluation survey.
        J Clin Urol. 2018; 12: 296-302
        • Ghani KR
        • Roghmann F
        • Sammon JD
        • et al.
        Emergency department visits in the United States for upper urinary tract stones: trends in hospitalization and charges.
        J Urol. 2014; 191: 90-96
        • Shoag JE
        • Patel N
        • Posada L
        • et al.
        Kidney stones and risk of narcotic use.
        J Urol. 2019; 202: 114-118
        • Assimos D
        • Krambeck A
        • Miller NL
        • et al.
        Surgical management of stones: American Urological Association/Endourological Society guideline, PART II.
        J Urol. 2016; 196: 1161-1169
        • Cui Y
        • Chen J
        • Zeng F
        • et al.
        Tamsulosin as a medical expulsive therapy for ureteral stones: a systematic review and meta-analysis of randomized controlled trials.
        J Urol. 2019; 201: 950-955
        • Loftus C
        • Nyame Y
        • Hinck B
        • et al.
        Medical expulsive therapy is underused for the management of renal colic in the emergency setting.
        J Urol. 2016; 195: 987-991
        • Tam CA
        • Dauw CA
        • Ghani KR
        • et al.
        New persistent opioid use after outpatient ureteroscopy for upper tract stone treatment.
        Urology. 2019; 134: 103-108
        • Large T
        • Heiman J
        • Ross A
        • Anderson B
        • Krambeck A
        Initial experience with narcotic-free ureteroscopy: a feasibility analysis.
        J Endourol. 2018; 32: 907-911
        • Sobel DW
        • Cisu T
        • Barclay T
        • Pham A
        • Callas P
        • Sternberg K
        A retrospective review demonstrating the feasibility of discharging patients without opioids after ureteroscopy and ureteral stent placement.
        J Endourol. 2018; 32: 1044-1049
      4. American Urological Association: AUA position statement: opioid use. Available at: https://www.auanet.org/guidelines/opioid-use. (Accessed April 12, 2020)

        • Koo K
        • Faisal F
        • Gupta N
        • et al.
        Recommendations for opioid prescribing after endourological and minimally invasive urological surgery: an expert panel consensus.
        J Urol. 2020; 203: 151-158
        • Portis AJ
        • Lundquist EL
        • Portis JL
        • et al.
        Unsuccessful medical expulsive therapy: a cost to waiting?.
        Urology. 2016; 87: 25-32
        • Hollingsworth JM
        • Wolf JS
        • Faerber GJ
        • Roberts WW
        • Dunn RL
        • Hollenbeck BK
        Understanding the barriers to the dissemination of medical expulsive therapy.
        J Urol. 2010; 184: 2368-2372
        • Pickard R
        • Starr K
        • MacLennan G
        • et al.
        Medical expulsive therapy in adults with ureteric colic: a multicentre, randomised, placebo-controlled trial.
        Lancet. 2015; 386: 341-349
        • Furyk JS
        • Chu K
        • Banks C
        • et al.
        Distal ureteric stones and tamsulosin: a double-blind, placebocontrolled, randomized, multicenter trial.
        Ann Emerg Med. 2016; 67: 86-95
        • Meltzer AC
        • Burrows PK
        • Wolfson AB
        • et al.
        Effect of tamsulosin on passage of symptomatic ureteral stones: a randomized clinical trial.
        JAMA Intern Med. 2018; 178: 1051-1057
        • Pathan SA
        • Mitra B
        • Cameron PA
        A systematic review and meta-analysis comparing the efficacy of nonsteroidal anti-inflammatory drugs, opioids, and paracetamol in the treatment of acute renal colic.
        Eur Urol. 2018; 73: 583-595
        • Pathan SA
        • Mitra B
        • Straney LD
        • et al.
        Delivering safe and effective analgesia for management of renal colic in the emergency department: a double-blind, multigroup, randomised controlled trial.
        Lancet. 2016; 387: 1999-2007
        • Sterrett SP
        • Moore NW
        • Nakada SY
        Emergency room follow-up trends in urolithiasis: single-center report.
        Urology. 2009; 73: 1195-1197
        • Ganesan V
        • Loftus CJ
        • Hinck B
        • et al.
        Clinical predictors of 30-Day emergency department revisits for patients with ureteral stones.
        J Urol. 2016; 196: 1467-1470
        • Brubaker WD
        • Dallas KB
        • Elliott CS
        • et al.
        Payer type, race/ethnicity, and the timing of surgical management of urinary stone disease.
        J Endourol. 2019; 33: 152-158
        • Kang C
        • Shu X
        • Herrel SD
        • et al.
        Opiate exposure and predictors of increased opiate use after ureteroscopy.
        J Endourol. 2019; 33: 480-485
        • Kang C
        • Shu X
        • Herrel SD
        • et al.
        Opiate exposure and predictors of increased opiate use after ureteroscopy.
        J Endourol. 2019; 33: 480-485
        • Minozzi S
        • Amato L
        • Davoli M
        Development of dependence following treatment with opioid analgesics for pain relief: a systematic review.
        Addiction. 2012; 108: 688-698