Does Achieving Your Own Access In Percutaneous Nephrolithotomy Decrease Pain and Opioid Use Among Patients?
MOHAMMAD H. HOUT, MD., MAXIMILIAN JENTZSCH, BS, MS., FRANCES KAZAL, BS, BORIVOJ GOLIJANIN, BS, TIMOTHY K. O'ROURKE, Jr., MD, NICOLE THOMASIAN, MD, PRAVEEN RAJAGURU, BS, GYAN PAREEK, MD., DAVID SOBEL, MD..
BROWN UNIVERSITY, PROVIDENCE, RI, USA.
BACKGROUND: Percutaneous nephrolithotomy (PCNL) is a combination of two procedures that first requires the establishment of percutaneous renal access followed by endoscopic stone fragmentation. At many institutions, renal access is obtained by interventional radiologists (IR) prior to stone treatment by urologists, whereas other urologists obtain access at the time of PCNL. While efforts to reduce opioid use during and after PCNL are ongoing, narcotic medications are still standard of care postoperatively for many urologists. We sought to compare the differences in opioid use in patients whose access is established by urology vs. IR at our institution.
METHODS: A retrospective analysis of 287 patients included from January 2016 - December 2020 undergoing PCNL at an academic institution was performed to compare those who had their nephrostomy access by IR vs. own urologist. IR access was performed in the radiology suite the same day under sedation, whereas urologist access was performed in the operating room at time of PCNL. Length of procedure was determined by times in the operating room alone. Opioid medication dosing was converted to morphine equivalent daily dosing (MEDD) for comparison. An ANOVA analysis was conducted for inpatient opioid use and outpatient opioid prescriptions to determine differences.
RESULTS: 287 patients were included in the analysis. 250 patients underwent PCNL with IR access vs. 37 patients with own urologist access over the time interval. 76.8% of IR group received opioids postoperatively while inpatient vs. 56.8% of own access patients (P=0.03). The IR group received a median of 10 morphine milligram equivalents/day (MEDD) on floor vs 7.5 MEDD for own access (P=0.194). Opioids were prescribed at discharge for 77.6% of IR vs. 56.8% for own access (p=0.012). MEDD of discharge opioids was 30 for both groups (p=0.226) but median quantity prescribed was 10 tablets for own access vs. 20 tablets for IR group(p=0.002). Length of procedure was 81 min for patients undergoing PCNL with urologist access vs 47 min for IR obtained access (p< 0.001). Length of stay was 31.5hrs for own access vs. 46hrs IR group (p=0.228). Differences in moderate-severe complications (Clavien-Dindo 3+) were not statistically significant between the two groups (3% for own access vs 11% for IR group (p=0.589).
CONCLUSIONS: Achieving nephrostomy access by the urologist at time of PCNL decreases opioid use for patients including MEDD dispensed as inpatients as well as outpatient opioid tablets prescribed, but at the cost of increased length of procedure. Further research is needed for opioid reduction strategies for patients undergoing either urologist or IR obtained access.
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