AUA 2019: Efficacy of Pethidine, Ketorolac and Lidocaine Gel as Analgesics for Pain Control in Shockwave Lithotripsy

Chicago, IL ( Treatment guidelines on urolithiasis recommend the administration of analgesia during shock wave lithotripsy (SWL). However, there are no specific recommendations as to the type of analgesia to be given. This is in contrast, for example, to well-defined recommendations for pain relief in an acute pain episode (renal colic). Proper analgesia for patients undergoing awake ESWL is very important because patient movements are likely to shift the stone outside of the focal zone of the shock waves. This, in turn, may result in longer operative time and reduced treatment efficacy.

Researchers from Egypt have noted that patients undergoing awake SWL at their institution often complain of dizziness, nausea, and vomiting after the administration of meperidine. They, therefore, sought to explore the utility of non-opioid analgesic agents in comparison to their standard practice (IV meperidine). Overall, 165 patients participated in this study and were divided into 3 groups. Included were patients with stones in either the kidney or the proximal ureter. Patients in group I (n=50) received bolus injection of IV meperidine 25 mg before SWL plus placebo gel (on flank) and IV meperidine 25 mg in slow drip during the procedure; patients in group II (n=53) received bolus injection of IV ketorolac 30 mg plus placebo gel and IV ketorolac 30 mg infusion during the procedure; patients in group III (n=29) received local lidocaine 2% gel on flank plus bolus injection of IV saline 10 mg followed by IV infusion of saline during the procedure.

Patients demographics and stone characteristics were comparable between the three groups. The procedure was aborted in 6 patients allocated to lidocaine gel plus IV placebo (group III) who could not tolerate the pain. As a result, total energy delivered was lower and session time was shorter in that group. All patients in the remaining 2 groups completed their planned SWL sessions. Median pain score was highest in the lidocaine group (up to 7/10 at 30 minutes), with no significant difference between ketorolac and meperidine, except at 10 minutes in favor of ketorolac. Patients receiving IV meperidine experienced higher rates of nausea and vomiting (36%) and had lower satisfaction scores. Of note, despite the potential risk of bleeding with the use of NSAIDs, there was no increased incidence of a postoperative perinephric hematoma. The authors concluded that IV ketorolac is a safe and effective alternative to opioid analgesia for awake SWL. Additionally, topical lidocaine gel should not be used as a sole analgesic agent in these cases.

Presented by Fady Kamal, University of Mansoura, Egypt
Authors: Abdelwahab Hashem, M. A. Elbaset, Ahmed Atwa, Mohamed Fadallah, Mahmoud Laymon, Mohammed Badawy, Magdy Elshabrawy, Mohamed Tharwat, Ebrahim Elsaeed, Mohammed Hegazy, Ahmed El-Assmy, Khaled Sheir, Hassan Abol-Enein
Affiliation: University of Mansoura, Egypt

Written by Shlomi Tapiero, MD (Department of Urology, University of California-Irvine) at the American Urological Association's 2019 Annual Meeting (AUA 2019), May 3 – 6, 2019 in Chicago, Illinois