AUA 2020: Pain Management in Urologic Surgery

( In a plenary session at the American Urologic Association (AUA) Virtual Annual Meeting this afternoon, Dr. Angela Smith moderated a session examining “Pain Management in Urologic Surgery”. Along with panelists Drs. Jay Simhan, Nicole Miller, and Ben Davies, Dr. Smith highlights issues relating to opioid use both widely in the community and specifically among surgical patients, as well as potential treatment approaches to decrease their utilization.

Beginning, Dr. Miller highlighted why this issue matters. She first highlighted that the odds of opioid overdose increased with duration of prescription and number of pills


Even among a relatively “minor” procedure such as outpatient ureteroscopy, Dr. Miller highlighted that there is a non-significant risk of persistent opioid use.


Further, patients who were treated with ureteroscopy for stone disease often received opioid prescriptions from more than 1 prescriber in the 3 months following treatment, indicative of potential doctor shopping. Increased opioid use was associated with preoperative opioid use, the number of prescriptions, the under of days prescribed, and the number of unique providers. Further, national-level data suggest a significant variation in opioid prescribing following minor urologic procedures.

For patients presenting with renal colic, Dr. Miller highlighted that first-line treatment for these patients is anti-inflammatory medications, including NSAIDs. Following endourologic intervention, pain control using NSAIDs, acetaminophen, anti-muscarinics, and alpha-blockers may allow for opiate sparing. She then described an early recovery after surgery (ERAS) protocol utilized in her institution.


She concluded by highlighting a recent expert consensus for post-operative prescribing, with opiate equivalents based on procedure.


Dr. Simhan then discussed pain management in prosthetics and male reconstruction. While the literature in this space often focuses on surgical technique, there is little data on pain control which may be a problem, particularly following IPP. Addressing the nociceptive pathway, he described a tailored multimodal analgesia pathway.


Use of this approach was shown to decrease opioid requirements, decrease pain scores, and cover the entire recovery process in a pilot study. Subsequent multi-institutional assessment among 203 patients undergoing IPP by 4 high volume implanters, use of multimodal approach, compared to opioid alone, was associated with lower pain in the PACU, POD0, and POD1 as well as decreased discharge narcotics.

Dr. Simhan closed by highlighting the importance of pain expectancy pre-operatively.

Dr. Davies then presented on the no opioid prostatectomy. His regime for this approach includes pre-operative, operative and post-operative approaches as follows:

Use of this approach is associated with lower opioid consumption with comparable patient-reported pain-related outcomes.


Presented by: Angela Smith, MD, MS, Vice Chair Of Academic Affairsdirector Of Urologic Oncologyassociate Professor of Urology, UNC School of Medicine, 

Jay Simhan, MD, FACS, Vice-Chairman of the Department of Urology and Director of Urologic Trauma, Reconstruction and Prosthetics for the Einstein Healthcare Network, Associate Professor of Urology at the Fox Chase Cancer Center and Residency Director of the Einstein Urology Residency Program
Nicole L. Miller, MD, FACS, Associate Professor, Department of Urology, Vanderbilt University Medical Center

Ben J. Davies, MD, Professor at the University of Pittsburgh School of Medicine, Chief of the Urology Section at the Shadyside/Hillman Cancer Center, Director of the Urologic Oncology Program, UPMC

Written by: Christopher J.D. Wallis, Urologic Oncology Fellow, Vanderbilt University Medical CenterContact: @WallisCJD on Twitter, at the 2020 American Urological Association (AUA) Annual Meeting, Virtual Experience #AUA20, June 27- 28, 2020

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