WCE 2018: Feasibility of a Non-Opioid Pathway for Postoperative Symptom Control After Ureteroscopy

Paris, France (UroToday.com) The opioid epidemic in recent years has continued to become a growing problem around the world, especially in the United States. The implication and expectation for patients to receive opioids for pain following surgical procedures has caused addiction and health risks that have reached crisis levels. Dr. David Sobel and his team of endourologists at the University of Vermont Medical center have recognized this drastic issue and have begun efforts to implement non-opioid protocols for outpatient urologic surgery.

The researchers have examined this issue in previous studies and have determined that ureteroscopy with stent placement (URS) is feasible without postoperative opioids. With this current study, the researchers intended to report long term follow-up with this approach and analyze factors associated with patients requiring postoperative opioids. 

In order to properly analyze this issue, a retrospective review of patients who underwent URS by a single surgeon between November 2016 to March 2018 was conducted. Postoperative medication treatment options were encouraged to avoid opioids by not giving postoperative prescriptions or diclofenac, an NSAID. Treatment options were assessed using the Treatment Algorithm (Figure 1). If patients had normal renal function and had no opioid tolerance, then they were eligible for the non-opioid treatment option, however, opioids were not prevented if necessary at discharge. Feasibility was evaluated by measuring the frequency of postoperative adverse events including visits to the emergency department (ED) for stent related complaints, stent-related telephone calls, and requests for pain medication prescription refills (Figure 2). 

Figure 1: The treatment algorithm for postoperative medication prescription, which is an aspect of the “Enhanced Recovery Stent Pathway” developed by Dr. Sobel and his team. This is part of “The Stent Toolkit” which is available for physicians on the website mentioned above. 

Figure 2: Adverse events during postoperative follow-up for routine URS in patients who were prescribed opioid or non-opioid medications.

Following accrual of subjects, it was shown that 206 patients underwent URS, of which, 151 patients were discharged without opioids (73%) while the remaining 55 received opioids (27%). Of the non-opioid cohort, 129 received diclofenac while 22 received no pain medication. Stent related visits to the ED were similar, as 13% of patients from the opioid group and 10% of patients from the non-opioid group went to the ED. Patients without opioids made significantly fewer telephone calls than those with opioids, a difference of 21% to 45%, respectively. The number of pain medication refill requests were also fewer among patients prescribed diclofenac than opioids, a difference of 7% to 24%. 

In closing, Dr. Sobel stressed the importance of the reduction of opioid prescriptions following endourological procedures. In his center’s experience, a non-opioid pathway reveals that approximately 3/4 of patients can be discharged after URS without opioids. Additionally, there were improvements in the number of adverse events experienced by the non-opioid cohort as related to the opioid cohort. Before he left the stage, Dr. Sobel shared a web link with his audience (www.stentpain.org) that led to the Consortium for Ureteral Stent Pain, a website created by the urologists at the University of Vermont. He recommended that the practicing endourologists in the room utilize this resource to improve patient understanding and expectations of stent pain. The site also offering tools for physicians such as The Stent Toolkit which recommends ways to properly treat patients for pain postoperatively without the necessity of opioids. 

Presented By: David Sobel  
Affiliation: University of Vermont Medical  

Written by: Zachary Valley, Department of Urology, University of California-Irvine medical writer for UroToday at the 36th World Congress of Endourology (WCE) and SWL - September 20-23, 2018 Paris, France