Opioid Use and Associated Patient Satisfaction With Pain Control After Endoscopic Surgery and Robotic-Assisted Radical Prostatectomy.

OBJECTIVE: To evaluate patient reported measures in patients undergoing endourologic procedures and robotic assisted radical prostatectomy (RARP) to demonstrate the efficacy of non-opioid postoperative pain management strategies. MATERIALS AND METHODS: A prospective cohort study performed at an academic medical center included a patient telephone questionnaire and chart review. Opioid prescriptions, opioid use, and patient reported outcomes were recorded. Bivariate analyses were used to compare patients who did and did not use opioids in the RARP cohort while overall trends were reported for the endourologic procedures. RESULTS: Of the 68 patients undergoing endoscopic intervention, 14 (21%) were prescribed an opioid and 6 (9%) reported any opioid use. 58 (85%) reported their pain was very well or well controlled while 9 reported their pain was poorly controlled. 59 (87%) were satisfied or very satisfied with their pain control. Fifty-three (93%) of the 57 patients undergoing RARP received an opioid prescription and only 23 reported any opioid use. All but 1 patient reported that their pain was well or very well controlled and almost all (54) of the patients were satisfied with their level of pain control. 36 (63%) reported their pain was less than expected while only 7 (12%) reported it was more than expected. CONCLUSION: Most patients undergoing endourologic procedures do not use postoperative opioids and report favorable outcomes regarding their pain control. Similarly, after RARP, most patients do not use opioids even when they are prescribed and are satisfied with their pain control.

Obstructing Ureteral Calculi and Presumed Infection: Impact of Antimicrobial Duration and Time From Decompression to Stone Treatment in Developing Urosepsis.

OBJECTIVE: To determine whether the duration of antibiotic treatment and timing between urgent renal decompression and stone intervention impacts the risk of developing urosepsis following definitive stone treatment. MATERIALS & METHODS: A retrospective review of patients who were diagnosed with obstructive urolithiasis and underwent urgent decompression with a ureteral double J stent or percutaneous nephrostomy at our institution between 2012 and 2018 was performed. We narrowed our analysis to the subset of patients who had suspected infection and received definitive stone treatment at our institution. Demographic, infection and antimicrobial data, and initial admission to stone treatment characteristics were collected. Factors associated with developing urosepsis were analyzed. RESULTS: We identified 872 patients who were treated with urgent renal decompression, of which 215 were analyzed that had suspected infection and also received definitive stone removal at our institution. Thirty-three had fevers, 64.2% had a positive urine culture, and 45.6% had urosepsis at the initial presentation. The median antibiotics duration post decompression was 13 days (IQR 8-18). The median duration from decompression to stone treatment was 17 days (IQR 12-27). Of all, 4.6% of the patients developed urosepsis post ureteroscopy and 5% post percutaneous nephrolithotomy. No factors were associated with developing urosepsis post stone treatment on logistic regression analyses. CONCLUSION: In patients requiring urgent decompression for obstructing urolithiasis and suspected infection, the time between decompression and stone treatment and the length of antibiotic exposure did not impact rates of postoperative urosepsis. This highlights the importance of maintaining high clinical suspicion for prolonged use of antibiotics, to prevent overtreatment and possible exacerbation of antibiotic resistance.

Association of Urine Findings with Metabolic Syndrome Traits in a Population of Patients with Nephrolithiasis.

Background: The odds of nephrolithiasis increase with more metabolic syndrome (MetS) traits. We evaluated associations of metabolic and dietary factors from urine studies and stone composition with MetS traits in a large cohort of stone-forming patients. Methods: Patients >18 years old who were evaluated for stones with 24-hour urine collections between July 2009 and December 2018 had their records reviewed retrospectively. Patient factors, laboratory values, and diagnoses were identified within 6 months of urine collection and stone composition within 1 year. Four groups with none, one, two, and three or four MetS traits (hypertension, obesity, dyslipidemia, and diabetes) were evaluated. Trends across groups were tested using linear contrasts in analysis of variance and analysis of covariance. Results: A total of 1473 patients met the inclusion criteria (835 with stone composition). MetS groups were 684 with no traits, 425 with one trait, 211 with two traits, and 153 with three or four traits. There were no differences among groups for urine volume, calcium, or ammonium excretion. There was a significant trend (P<0.001) for more MetS traits being associated with decreasing urine pH, increasing age, calculated dietary protein, urine uric acid (UA), oxalate, citrate, titratable acid phosphate, net acid excretion, and UA supersaturation. The ratio of ammonium to net acid excretion did not differ among the groups. After adjustment for protein intake, the fall in urine pH remained strong, while the upward trend in acid excretion was lost. Calcium oxalate stones were most common, but there was a trend for more UA (P<0.001) and fewer calcium phosphate (P=0.09) and calcium oxalate stones (P=0.01) with more MetS traits. Conclusions: Stone-forming patients with MetS have a defined pattern of metabolic and dietary risk factors that contribute to an increased risk of stone formation, including higher acid excretion, largely the result of greater protein intake, and lower urine pH.

Urological Education in United States Medical Schools: Where Are We Now and How Can We Do Better?

INTRODUCTION: While urological complaints increase in aging populations and conditions commonly require management by multiple physician specialty types, exposure to formal urological education in United States medical schools is limited and has been decreasing over time. We aim to update the current status of urological education in the United States curriculum and delve further into the subject matter being taught and the type and timing of this education. METHODS: An 11-question survey was developed to describe the current status of urological education. The survey was distributed using Survey Monkey to the American Urological Association's medical student listserv in November 2021. Descriptive statistics were used to summarize survey findings. RESULTS: Of 879 invitations sent, 173 responded (20%). Most (112/173, 65%) of respondents were in their fourth year. Only 4 (2%) reported that their school had a required clinical urology rotation. Kidney stones (98%) and urinary tract infections (100%) were the most frequent topics taught. The least exposure included infertility (20%), urological emergencies (19%), bladder drainage (17%), and erectile dysfunction (13%). Videos and case vignettes were the preferred learning modalities and the majority (84%) of respondents were familiar with the American Urological Association's medical student curriculum material. CONCLUSIONS: The majority of United States medical schools do not have a required clinical urology rotation and some core urological topics are not taught at all. Future incorporation of urological educational material through video and case vignette learning may be the best opportunity to provide exposure to clinical topics that will commonly be encountered regardless of chosen medical discipline.

Opioids and Kidney Stones.

In recent years, the use of opioids in medical practice has come under significant scrutiny. This, in part, is owing to evidence of overprescription and overuse of opioid medications, as well as the unintended consequences and side effects for patients who take these medications. Here, we review the role of opioids and the responsible use of these medications with respect to kidney stone disease and surgical interventions for kidney stones.

Laboratory Reporting Parameters of Microhematuria: Implications for Interpreting the 2020 AUA Guideline.

OBJECTIVE: To explore how laboratories in the United States (U.S.) report red blood cell per high powered field (RBC/HPF) counts on urinalysis and to evaluate whether this methodology permits effective risk stratification in accordance with the 2020 AUA/SUFU microhematuria guidelines. MATERIALS AND METHODS: Reporting methods for RBC/HPF counts (ranges, or actual counts) were collected by querying urologists in U.S. academic medical institutions or commercial laboratories. We explore whether (1) the reporting schemes were concordant with the risk strata in the new microhematuria guideline (3-10 [low risk], 11-25 [intermediate risk], and more than 25 [high risk]), and (2) evaluate the potential for risk group misclassification based on reporting methodology. RESULTS: Data were available for 141 laboratories. Seventy-two (51%) use RBC/HPF ranges, while the remainder use actual counts (or counts to a threshold). Sixty (42%) report range cutoffs which are not concordant with the microhematuria guidelines risk groups. Furthermore, fifty-six (40%) do not include the cutoff of 25 RBC/HPF which could potentially misclassify intermediate and high risk groups. Finally, sixteen (11%) do not include the cut-off of 3 RBC/HPF that defines the presence of microhematuria. CONCLUSION: A significant number of laboratories report RBC/HPF counts in ranges that differ from thresholds in the 2020 AUA/SUFU guideline. The implication is potential misclassification of microhematuria both at minimum threshold diagnosis (3 RBC/HPF), and additionally between intermediate and high risk groups. Standardization of reporting schemes to actual RBC/HPF counts may allow improved adherence to guidelines while providing data for future guideline development.

Patterns of opioid prescription post ureteroscopy among members of the Endourological Society.

BACKGROUND: Postoperative opioid prescribing has been linked with persistent opioid use. Ureteroscopy (URS) is a common urologic procedure and a potential area to focus on opioid reduction. We aim to characterize international practice patterns of opioid prescribing post URS and what measures may decrease the need for opioid prescription. METHODS: We developed a survey directed to members of the Endourological Society. The survey queried the frequency of opioid prescribing post URS, challenges when opioids are not prescribed, and measures thought to reduce the need for opioids. RESULTS: We received 159 responses with the majority reported practicing urology for >20 years (37.1%), and performing 10-20 ureteroscopies/month (45.3%). Forty-one percent were from the United States (US) and Canada. Sixty-six percent completed a fellowship, 84% in endourology. Twenty-six percent prescribe opioids more than half the time and the majority do so less than 10% of the time (61.6%). Thirty-eight percent had no challenges when opioids were omitted. Measures felt to decrease the need for opioids were preoperative counseling, nonsteroidal anti-inflammatory drugs use, and use of adjunct medications. After adjusting for location and type of practice, endourology fellowship completion, years of practice, and number of ureteroscopies/month, we found that respondents from the US and Canada were more likely to prescribe opioids more than half the time post URS compared to respondents from the rest of the world [odds ratio (OR): 87.5, P<0.001, 95% confidence interval (CI): 17.3-443.5]. CONCLUSIONS: Despite proven feasibility of non-opioid pathway, nearly one-quarter of participants in our survey prescribe opioids >50% of the time post URS. Most important factors felt to reduce opioid prescription post URS were preoperative counseling, nonsteroidal anti-inflammatory drugs use. US and Canadian urologists were more likely to prescribe opioids >50% of the time post URS compared to the rest of the world. We believe best practice guidelines should be considered by the American and Canadian Urological Associations to address post URS opioid prescribing.

National Imaging Trends in Nephrolithiasis-Does Renal Ultrasound in the Emergency Department Pave the Way for Computerized Tomography?

INTRODUCTION: Concern regarding radiation exposure has led to increased interest in the use of ultrasound for the initial imaging of suspected renal colic in the emergency department. It is unknown whether such an approach simply defers computerized tomography to outpatient followup. We analyzed national imaging patterns to explore this relationship. METHODS: Using the MarketScan® insurance claims database we reviewed adult patients newly diagnosed with nephrolithiasis in U.S. emergency departments between 2007 and 2015. Patients were excluded if they had been diagnosed with or undergone treatment for nephrolithiasis in the preceding 180 days. RESULTS: From 2007 to 2015, 830,785 emergency department nephrolithiasis encounters met inclusion criteria. The ultrasound-only rate increased from 2.7% to 6.9%, while the computerized tomography-only rate remained stable at 85.8%. A history of computerized tomography in the 30 days before emergency department presentation increased the rate of ultrasound-only imaging from 4.6% to 8.9%. The mean cumulative computerized tomography scans from the emergency department visit to 90 days after was significantly lower in those imaged with emergency department ultrasound (0.82±0.77) compared to those imaged with emergency department computerized tomography (1.2±0.51, p <0.001). CONCLUSIONS: Patients who undergo ultrasonography in the emergency department for evaluation of renal colic undergo fewer cumulative computerized tomography scans in the 90 days following their visit than do patients initially imaged with computerized tomography. Ultrasound use for the evaluation of renal colic has increased while computerized tomography rates have remained stable.

Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus.

PURPOSE: Renal colic is common and CT (computerized tomography) is frequently utilized when the diagnosis of kidney stone is suspected. CT is accurate, but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multi-organizational transdisciplinary collaboration sought evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting. MATERIALS AND METHODS: In conjunction with the ACEP (American College of Emergency Physicians®) E-QUAL (Emergency Quality Network) we formed a nine-member panel with three physician representatives each from the ACEP, the ACR® (American College of Radiology) and the AUA (American Urological Association). A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios. RESULTS: From an initial search yielding 6,337 records there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%) and moderate in 3 (10%) of the 29 scenarios. There were no scenarios where at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%) with ultrasound in 9 (31%) and no further imaging needed in 13 (45%). CONCLUSIONS: Evidence and multispecialty consensus support ultrasound or no further imaging in specific clinical scenarios, with reduced-radiation dose CT to be employed when CT is needed in patients with suspected renal colic.

Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus.

STUDY OBJECTIVE: Renal colic is common and computed tomography (CT) is frequently used when the diagnosis of kidney stone is suspected. CT is accurate but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multiorganizational transdisciplinary collaboration seeks evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting. METHODS: In conjunction with the American College of Emergency Physicians (ACEP) Emergency Quality Network, we formed a 9-member panel with 3 physician representatives each from ACEP, the American College of Radiology, and the American Urology Association. A systematic literature review was used as the basis for a 3-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios. RESULTS: From an initial search yielding 6,337 records, there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, out of the 29 scenarios agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%), and moderate in 3 (10%). There were no scenarios in which at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%), with ultrasonography in 9 (31%) and no further imaging needed in 12 (45%). CONCLUSION: Evidence and multispecialty consensus support ultrasonography or no further imaging in specific clinical scenarios, with reduced-radiation-dose CT to be used when CT is needed for patients with suspected renal colic.

Imaging in Suspected Renal Colic: Systematic Review of the Literature and Multispecialty Consensus.

BACKGROUND: Renal colic is common, and CT is frequently utilized when the diagnosis of kidney stones is suspected. CT is accurate but exposes patients to ionizing radiation and has not been shown to alter either interventional approaches or hospital admission rates. This multi-organizational transdisciplinary collaboration sought evidence-based, multispecialty consensus on optimal imaging across different clinical scenarios in patients with suspected renal colic in the acute setting. METHODS: In conjunction with the American College of Emergency Physicians (ACEP) eQual network, we formed a nine-member panel with three physician representatives each from ACEP, the ACR, and the American Urology Association. A systematic literature review was used as the basis for a three-step modified Delphi process to seek consensus on optimal imaging in 29 specific clinical scenarios. RESULTS: From an initial search yielding 6,337 records, there were 232 relevant articles of acceptable evidence quality to guide the literature summary. At the completion of the Delphi process consensus, agreement was rated as perfect in 15 (52%), excellent in 8 (28%), good in 3 (10%), and moderate in 3 (10%) of the 29 scenarios. There were no scenarios where at least moderate consensus was not reached. CT was recommended in 7 scenarios (24%), with ultrasound in 9 (31%) and no further imaging needed in 12 (45%). SUMMARY: Evidence and multispecialty consensus support ultrasound or no further imaging in specific clinical scenarios, with reduced-radiation dose CT to be employed when CT is needed in patients with suspected renal colic.

American Urological Association, American College of Emergency Physicians and American College of Radiology Quality Improvement Summit 2017: Challenges and Opportunities for Stewardship of Urological Imaging.

INTRODUCTION: Since 2014 the AUA (American Urological Association) has convened several Quality Improvement Summits to provide education and promote dialogue around issues of quality improvement and patient safety. The 2017 Summit, Challenges and Opportunities for Stewardship of Urological Imaging, organized in partnership with the American College of Radiology and the American College of Emergency Physicians, highlighted opportunities for collaborative improvement in the value, safety and quality of imaging for patients with urological conditions. METHODS: The Summit was held at AUA headquarters in Linthicum, Maryland on October 21, 2017. Each talk, panel and working group held during the summit highlighted gaps in care being addressed by physician led stewardship initiatives in imaging, in general, as well as multiple specific examples related to prostate cancer and urinary stone disease. RESULTS: Presentations facilitated information exchange on quality efforts between clinicians across disciplines and care settings and served to educate urology practitioners, primary care physicians, and specialists about existing patient centered quality improvement programs. CONCLUSIONS: This exchange serves to accelerate adoption of evidence-based practices and brings together stakeholder organizations to form partnerships that facilitate the further development of research and policy agendas to advance physician led stewardship of advanced imaging across emergency medicine, radiology and urology. In parallel, this meeting established a consortium to develop and disseminate tools for facilitating organizational improvement activities needed to enhance the quality and safety of medical care.

Discharge materials provided to patients with kidney stones in the emergency department may be a source of misinformation.

INTRODUCTION: Renal colic is commonly seen in the emergency department (ED), where the focus is on diagnosis and symptom control. Educational materials are sometimes provided upon discharge, however, no standard content has been established. We characterized the educational materials given to patients reporting to EDs in different regions across the U.S. for symptomatic kidney stones, specifically evaluating disease-specific information, symptom management, prevention strategies including dietary recommendations (DRs), and patient follow up plans. MATERIALS AND METHODS: Generic discharge instructions for patients presenting to EDs with renal colic were obtained from community hospitals and academic medical centers between October 2016 and November 2017. Hospitals were called directly. If the same discharge instructions were used by more than one hospital, each was included in our analysis. We assessed the different types of information provided with a focus on stone prevention and DRs by characterizing them into specific nutritional categories. RESULTS: Of 266 hospitals contacted, 79 provided discharge instructions. Of these, 51 (65%) provided some information on diet. While most recommended higher fluid intake, almost 40% endorsed unnecessary fluid restrictions. Recommendations to reduce protein and oxalate intake were common, but erroneous information for both was given. Nearly 1 in 5 EDs recommended lower calcium intake. Less than 30% of EDs mentioned that stones can have different composition or causes. Less than 30% referenced consultation with a registered dietitian nutritionist (RDN) or that dietary approaches to stone prevention are optimally individualized. Only 9 summaries recommended urologic follow up. CONCLUSIONS: Many ED discharge materials contain DRs for stone prevention. These recommendations can be inaccurate and/or inappropriate. Advice on diet and stone prevention is more appropriately addressed in the outpatient setting when more data (stone composition, serum and urine parameters) and expert consultants are available.