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A retrospective pilot study comparing the efficacy of opioids and diclofenac for post-ureteroscopy pain control
David W. Sobel, MD, Theodore Cisu, BS, Kevan M. Sternberg, MD.
University of Vermont, Burlington, VT, USA.
BACKGROUND: Despite playing an important part in the palliation of symptoms and treatment of nephrolithiasis, ureteral stents remain a source of significant morbidity for urologic patients. With growing concern regarding narcotic medication prescriptions for the management of postoperative pain, alternative medications have been proposed. Recent basic science and translational research has identified the benefit of prostaglandin inhibition in ureteric smooth muscle for renal colic using non-steroidal anti-inflammatory drugs (NSAIDs) such as diclofenac. In this study, we evaluate the efficacy of diclofenac compared to opioids given postoperatively as determined by frequency of stent symptom-related adverse events.
METHODS: Charts of 101 patients who underwent ureteroscopy with stent placement over a three-month period (November-February) in 2015-2016 and the same interval in 2016-2017 were reviewed retrospectively. All procedures were performed by a single surgeon. In the first interval, routine post-ureteroscopy discharge medications included opiate medications for pain control. During the second interval, diclofenac was substituted for opiate prescriptions upon discharge for appropriately selected patients without history of renal dysfunction or prior opioid tolerance. Study exclusion criteria included ureteroscopy without stent placement, or receiving both an opiate and diclofenac or neither on discharge. Efficacy of the medication was determined by measuring the frequency of adverse events postoperatively including visits to the emergency room for stent symptoms, stent symptom related telephone calls to the urology clinic, unexpected urologic interventions such as early stent removal, and requests for prescription refills for pain medication.
RESULTS: In the first time interval, 37 ureteroscopies with stent placement were performed and 31 patients were discharged with opioid prescriptions (83.7%). In the second time interval, for which an asserted effort was made to avoid opioid medications, 51 ureteroscopies with stent placement were performed. 33 patients were discharged without opioid prescriptions (64.7%). Of these, 27 received diclofenac and 6 patients received neither medication. A similar percentage of patients receiving only opioids in the first interval and only diclofenac in the second had postoperative visits to the emergency room for genitourinary-related concerns (5 patients receiving opioids (16.1%) and 6 patients receiving diclofenac (22.2%); p=0.556) and to clinic for early stent removal (5 patients receiving opioids (16.1%) and 4 patients receiving diclofenac (14.8%); p=0.892). Patients in the second interval prescribed diclofenac made a similar number of telephone calls compared to patients in the first interval prescribed opioids (10 patients receiving opioids (32.3%) and 9 patients receiving diclofenac (33.3%); p=.936) and patients given diclofenac at discharge tended to request fewer pain medication refills, although this was not statistically significant (6 patients receiving opioids (19.4%) and 1 patient receiving diclofenac (3.7%); p=0.073).
CONCLUSIONS: This retrospective pilot study demonstrates the feasibility of diclofenac as alternative to opioid pain medications for post-ureteroscopy pain control in appropriately selected patients. In the patient group that received diclofenac, there were no significant differences in the rate of postoperative adverse events. Understandably, this preliminary data is based on small patient numbers. Future larger prospective studies are warranted to better evaluate the efficacy of this medication for post-ureteroscopy and ureteral stent pain.
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