Analgesia for patients undergoing shockwave lithotripsy for urinary stones – a systematic review and meta-analysis

ABSTRACT Background Shock wave lithotripsy (SWL) is the first line treatment modality for a significant proportion of patients with upper urinary tracts stones. Simple analgesics, opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are all suitable agents but the relative efficacy and tolerability of these agents is uncertain. Objectives To determine the efficacy of the different types of analgesics used for the control of pain during SWL for urinary stones. Materials and Methods We searched the Cochrane Renal Group’s Specialised Register, MEDLINE, EMBASE and also hand-searched reference lists of relevant articles (Figure-1). Randomised controlled trials (RCT’s) comparing the use of any opioid, simple analgesic or NSAID during SWL were included. These were compared with themselves, each-other or placebo. We included any route or form of administration (bolus, PCA). We excluded agents that were used for their sedative qualities. Data were extracted and assessed for quality independently by three reviewers. Meta-analyses have been performed where possible. When not possible, descriptive analyses of variables were performed. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals. Results Overall, we included 9 RCTs (539 participants from 6 countries). Trial agents included 7 types of NSAIDs, 1 simple analgesic and 4 types of opioids. There were no significant differences in clinical efficacy or tolerability between a simple analgesic (paracetamol) and an NSAID (lornoxicam). When comparing the same simple analgesic with an opioid (tramadol), both agents provided safe and effective analgesia for the purpose of SWL with no significant differences. There were no significant differences in pain scores between NSAIDs or opioids in three studies. Adequate analgesia could be achieved more often for opioids than for NSAIDs (RR 0.358; 95% CI 043 to 0.77, P=0.0002) but consumed doses of rescue analgesia were similar between NSAIDs and opioids in two studies (P=0.58, >0.05). In terms of tolerability, there is no difference in post-operative nausea and vomiting (PONV) between the groups (RR 0.72, 95% CI 0.24 to 2.17, P=0.55). One study compared outcomes between two types of NSAIDs (diclofenac versus dexketoprofen). There were no significant differences in any of our pre-defined outcomes measures. Conclusion Simple analgesics, NSAIDs and opioids can all reduce the pain associated with shock wave lithotripsy to a level where the procedure is tolerated. Whilst there are no compelling differences in safety or efficacy of simple analgesics and NSAIDs, analgesia is described as adequate more often for opioids than NSAIDs.

Analgesia for patients undergoing shockwave lithotripsy for urinary stones - a systematic review and meta-analysis.

BACKGROUND: Shock wave lithotripsy (SWL) is the first line treatment modality for a significant proportion of patients with upper urinary tracts stones. Simple analgesics, opioids and non-steroidal anti-inflammatory drugs (NSAIDs) are all suitable agents but the relative efficacy and tolerability of these agents is uncertain. OBJECTIVES: To determine the efficacy of the different types of analgesics used for the control of pain during SWL for urinary stones. MATERIALS AND METHODS: We searched the Cochrane Renal Group's Specialised Register, MEDLINE, EMBASE and also hand-searched reference lists of relevant articles (Figure-1). Randomised controlled trials (RCT's) comparing the use of any opioid, simple analgesic or NSAID during SWL were included. These were compared with themselves, each-other or placebo. We included any route or form of administration (bolus, PCA). We excluded agents that were used for their sedative qualities. Data were extracted and assessed for quality independently by three reviewers. Meta-analyses have been performed where possible. When not possible, descriptive analyses of variables were performed. Dichotomous outcomes are reported as relative risk (RR) and measurements on continuous scales are reported as weighted mean differences (WMD) with 95% confidence intervals. RESULTS: Overall, we included 9 RCTs (539 participants from 6 countries). Trial agents included 7 types of NSAIDs, 1 simple analgesic and 4 types of opioids. There were no significant differences in clinical efficacy or tolerability between a simple analgesic (paracetamol) and an NSAID (lornoxicam). When comparing the same simple analgesic with an opioid (tramadol), both agents provided safe and effective analgesia for the purpose of SWL with no significant differences. There were no significant differences in pain scores between NSAIDs or opioids in three studies. Adequate analgesia could be achieved more often for opioids than for NSAIDs (RR 0.358; 95% CI 043 to 0.77, P=0.0002) but consumed doses of rescue analgesia were similar between NSAIDs and opioids in two studies (P=0.58, >0.05). In terms of tolerability, there is no difference in post-operative nausea and vomiting (PONV) between the groups (RR 0.72, 95% CI 0.24 to 2.17, P=0.55). One study compared outcomes between two types of NSAIDs (diclofenac versus dexketoprofen). There were no significant differences in any of our pre-defined outcomes measures. CONCLUSION: Simple analgesics, NSAIDs and opioids can all reduce the pain associated with shock wave lithotripsy to a level where the procedure is tolerated. Whilst there are no compelling differences in safety or efficacy of simple analgesics and NSAIDs, analgesia is described as adequate more often for opioids than NSAIDs.

Laparoscopic nephrectomy - Pfannenstiel or expanded port site specimen extraction: a systematic review and meta-analysis.

INTRODUCTION: To anaylse the current evidence regarding the safety, feasibility and advantages of intact specimen extraction via various extraction sites after conventional laparoscopic nephrectomy (LN). MATERIAL AND METHODS: A comprehensive literature search was performed identifying studies evaluating outcomes from Pfannenstiel (PFN) versus extended port site (EPS) extraction sites, after conventional laparoscopic nephrectomy/nephroureterectomy (LRN/LNU) and donor nephrectomy (LDN). Outcome measures included procedure duration, incision length, duration of inpatient stay, analgesic requirements, complications and warm ischemia time (for donor nephrectomy cases). RESULTS: This systematic review of five comparative studies found no significant difference in morbidity, wound length, wound complications or opioid consumption across all studies. Inpatient stay (p = 0.03) and estimated blood loss (p = 0.03) were significantly less in favour of a PFN extraction site. When comparing radical nephrectomy cases alone, the PFN group had a shorter procedure time (NS), less estimated blood loss (p = 0.04), shorter inpatient stay (p <0.05), significantly less morphine use (p <0.006) and fewer wound complications. CONCLUSIONS: This review demonstrates the viability of retrieving a nephrectomy specimen/graft through a PFN incision in relation to the benefits of cosmesis and reduced pain. As reported in several trials, morbidity is not significantly increased and key outcome measures, such as duration of inpatient stay, pain scores, complications, analgesic requirements and time taken to return to normal activities, remain non-inferior. This study is limited by the small number of generally low quality studies available for analysis. Further well-constructed randomised controlled trials are needed to shed more light on this subject area.

Intracranial metastasis of adenocarcinoma of the prostate presenting with symptoms of spinal cord compression.

Spinal cord compression is a not uncommon complication of metastatic prostate cancer. Intracranial metastasis of prostatic adenocarcinoma is however unusual. We report a case of a 67-year-old man with metastatic prostate carcinoma, who presented with a 3-day history of lower limb weakness and collapse. Neurological assessment demonstrated increased tone and reduced power in both legs. As he had typical signs and symptoms of spinal cord compression, an MRI of the spine was performed; this demonstrated no evidence of cord compression. A subsequent CT of the brain demonstrated an extensive parafalcine metastasis. This revealed an extensive enhancing mass extending bilaterally along almost the entire length of the falx cerebri, measuring up to 3 cm in width and associated with marked white matter oedema in the adjacent brain bilaterally. Unfortunately, this man succumbed to his illness a few days later. The imaging findings are presented and highlight the importance of brain imaging in patients presenting with suspected cord compression due to prostatic metastatic disease when MR of the spine shows no evidence of cord compression.

Loss of cytochrome c oxidase promotes RAS-dependent ROS production from the ER resident NADPH oxidase, Yno1p, in yeast.

Many disease states, including the aging process, are associated with the accumulation of mitochondria harboring respiratory dysfunction. Mitochondrial dysfunction is often accompanied by increased ROS levels that can contribute to cellular dysfunction and disease etiology. Here we use the model eukaryote S. cerevisiae to investigate whether reduced cytochrome c oxidase (COX) activity, commonly reported in aging organisms and associated with neurodegenerative disorders, leads to ROS production from mitochondria. We provide evidence that although reduced COX complex activity correlates with ROS accumulation, mitochondria are not the major production center. Instead we show that COX-deficient mitochondria activate Ras upon their outer membrane that establishes a pro-ROS accumulation environment by suppressing antioxidant defenses and the ERAD-mediated turnover of the ER-localized NADPH oxidase Yno1p. Our data suggest that dysfunctional mitochondria can serve as a signaling platform to promote the loss of redox homeostasis, ROS accumulation, and accelerate aging in yeast.