Unveiling the impact of opioid-free postoperative regimens in ureteroscopy: a comprehensive systematic review and meta-analysis.

INTRODUCTION: Ureteroscopy (URS) and retrograde intrarenal surgery (RIRS) are minimally invasive urologic procedures that are commonly used to treat kidney stones. However, they often result in significant postoperative pain. Historically, patients undergoing these surgeries have predominantly been managed with opioids, which has contributed to the escalating global complications associated with these drugs, including abuse and addiction. As a result, over the recent years, many healthcare centers have made efforts to minimize opioid use, opting instead for safer alternative medications. In this study, we aim to compare the efficacy of both opioid and opioid-free pain management regimens following URS or RIRS procedures. EVIDENCE ACQUISITION: A systematic search was conducted in MEDLINE, Embase, Scopus, Cochrane, LILACS, and Google Scholar. We included studies that compared opioid-based and opioid-free postoperative care for managing pain in patients who underwent URS or RIRS for lithotripsy. Our primary outcome of interest was the frequency of postoperative emergency department (ED) visits. Secondary outcomes included pain-related phone calls, postoperative unexpected encounters, need for opioids at discharge, and patients with opioid refills. EVIDENCE SYNTHESIS: We retrieved 10 articles, encompassing 6786 patients in the opioid group and 5276 patients in the opioid-free group. Overall, our findings lean towards favoring the opioid-free regimen, revealing notable differences between the groups. Opioid-free regimen was associated with less ED visits (OR=0.67; 95% CI: 0.58, 0.77; P=0.00001; I2=0%) and required less opioids at discharge (OR=0.11; 95% CI 0.02, 0.64; P=0.01; I2=89%). CONCLUSIONS: Through statistically superior results, our meta-analysis suggests that an opioid-free regimen outperforms the use of opioids after URS or RIRS, particularly in terms of pain management.

Effect of irrigation solution temperature on complications of percutaneous nephrolithotomy: a systematic review of the literature, meta-analysis and trial sequential analysis of randomized clinical trials.

INTRODUCTION: The optimal temperature of irrigation solution in patients undergoing PCNL is still unclear. Accordingly, this study aims to investigate the effects of different irrigation solution temperatures (cold/room temperature irrigation fluid versus warm/body temperature fluid). Our primary endpoint was hypothermia rate. Secondary outcomes were shivering rate, mean temperature decrease, mean patient final temperature, blood loss, and operative time. EVIDENCE ACQUISITION: This systematic review was conducted in accordance with PRISMA guidelines. Multiple databases were searched in November 2023. Among 299 studies screened, eight were selected for full-text review, resulting in four randomized clinical trials that fit inclusion criteria and desired outcomes. Studies selection and data extraction were performed by multiple reviewers and a random-effects model was used for pooling of data. EVIDENCE SYNTHESIS: The primary outcome, hypothermia rate, showed a significant statistical difference between groups, occurring less frequently in the experimental group (35-37 ºC) than in the cold/room temperature irrigation group (RR 0.64;95%CI 0.46, 0.89; P<0.008; I2=33%). Secondary outcomes such as shivering rate (RR 0.46; 95%CI 0.31, 0.67; P<0.0001; I2=0%) and mean final temperatures (MD 0.43; 95%CI 0.12, 0.75; I2=82%) also showed statistically significant differences between groups, favoring the irrigation with heated fluid. CONCLUSIONS: There was a decreased rate of hypothermia and shivering among patients undergoing PCNL with warm irrigation fluid. Mean final temperatures were also higher in the experimental group. As to blood loss, mean hemoglobin decrease showed no statistically significant difference between groups, prompting further investigation of the influence of Irrigation solution temperature on blood loss volume.

PCNL vs. two staged RIRS for kidney stones greater than 20 mm: systematic review, meta-analysis, and trial sequential analysis.

INTRODUCTION: Percutaneous nephrolithotomy (PCNL) is considered the gold standard treatment for kidney stones greater than 20 mm. However, retrograde intrarenal surgery (RIRS) may achieve the same stone-free rate with repeated procedures, and potentially fewer complications. This study aimed to compare the efficacy and safety of PCNL and two-staged RIRS. EVIDENCE ACQUISITION: We conducted a systematic search in PubMed, Embase, Scopus, Cochrane, and Web of Science for studies comparing PCNL and RIRS for kidney stones greater than 20mm. The primary outcome is stone-free rate (SFR) of PCNL and RIRS (repeated once if needed). Secondary outcomes were SFR of PCNL versus RIRS (single procedure), operative time, hospital stay, need for auxiliary procedures, and complications. We performed a subgroup analysis for randomized trials, non-randomized trials, and patients with solitary kidney. We performed a trial sequential analysis for the main outcome. EVIDENCE SYNTHESIS: We included 31 articles, with 1987 patients in the PCNL and 1724 patients in RIRS. We confirmed the traditional result that after a single procedure PCNL has a higher SFR. We also found that comparing the SFR of PCNL and RIRS, repeated up to two times if needed, no difference in SFR was observed. Surprisingly, only 26% (CI95 23%-28%) of the patients required a second RIRS. In the trial sequential analysis, the last point of the z-curve was within futility borders. We observed that PCNL has a higher incidence of complications (RR=1.51; CI95 1.24, 1.83; P<0.0001; I2=28%), specifically CD2 (RR=1.82; CI95 1.30, 2.54; P=0.0004; I2=26%) and longer hospital stay (MD 2.57; 2.18, 2.96; P<0.00001; I2-98%). No difference was observed regarding operative time. CONCLUSIONS: RIRS repeated up to two times is equivalent to PCNL in terms of the SFR and may have the same safety.