Presentation Authors: Nadeem Iqbal*, Hasan Aisha, Lahore, Pakistan, Umar Alam, Islamabad, Pakistan, Rahim Waqas, Tauqeer Fiaz, Zafar Nauman, bhatty Tanweer, Saeed Akhter, Lahore, Pakistan
Introduction: Recently it has been noted that efforts have been made to implement non-opioid protocols for outpatient urologic surgery. Literature in recent past has demonstrated that ureteroscopy (URS) with stent placement is possible without using postoperative opioids for pain control and stent-related symptoms. In this study, we evaluated the feasibility of a non-opioid discharge protocol compared to standard opioid medications for postoperative pain following URS and stent placement over a 8 months period.
Methods: Charts review of patients who underwent URS with stent placement was done over a 8-month period from February 2018 to October 2018 were retrospectively reviewed. Patients were discharged on paracetamol or diclofenac (NSAID) or tramadol (opioid) in groups 1,2 and 3 respectively. Patients having normal renal function and no evidence of current or prior opioid tolerance were included in the study. We noted the frequency of postoperative events including visits to the emergency room (ER) for stent-related symptoms, and need for prescription refills for these 3 groups. Postoperative pain intensity was measured by nurse in the recovery room and at 0,6, 12, 24, 48, & 72 hours using the Verbal Intensity Pain Scale (VIPS).A mean pain score of less than 2 for each category of surgical procedures or analgesics group was defined as satisfactory pain control. Anova t test was applied to see for statistically significant difference in mean pain scores between these groups.
Results: Total of 120 patients underwent URS with double j stent placement: with 40 patients in each group. Eighty patients (of group 1 and 2) were not given opioids and were then discharged on opioid free pain killer. The mean pain score was >2 at 6 h postoperative in all three groups. However pain was satisfactorily controlled in 90%, 92.5% and 90% in the respective groups 1,2 and 3 (p=0.09). Of those discharged without an opioid, 60 received paracetamol and and 20 received diclofenac as pain killer. It was noted that the different analgesics prescribed for postoperative pain management provided satisfactory pain control based on mean pain score obtained at different intervals during 3 days after the surgery. There was no difference in the percentage of patients who had postoperative visits to the ER for genitourinary-related concerns (3/40 patients receiving opioids and 7/80 patients without opioids; p=0.89). The number of additional pain killers need for refill was similar between the three groups (5/40 patients receiving opioids (12.5%) and 8/80 patients without opioids (10.%); p=0.19).
Conclusions: This study demonstrates the feasibility of a non-opioid postoperative protocol even in acute setting in recovery for those undergoing URS in carefully selected patients. Compared to patients receiving opioids, these patients receiving non-opioid therapies had similar pain scores in 3 days after surgery and similar pain killers refill requests. There should be such studies on other urologic procedure as well in future to look for Non opioids and even NSAIDS free pain killers.