Contribution of Hypersensitivity to Postureteroscopy Ureteral Stent Pain: Findings From Study to Enhance Understanding of Stent-associated Symptoms

OBJECTIVE

To examine the relationships between preoperative hypersensitivity to pain and central sensitization, and postoperative ureteral stent pain after ureteroscopy (URS) for urinary stones.

METHODS

Adults enrolled in the STudy to Enhance uNderstanding of sTent-associated Symptoms (STENTS) underwent quantitative sensory testing (QST) prior to URS and stent placement. Hypersensitivity to mechanical pain was assessed using a pressure algometer. Participants rated their pain intensity to pressure applied to the ipsilateral flank area and lower abdominal quadrant on the side of planned stent placement, and the contralateral forearm (control). Pressure pain thresholds were also assessed. Central sensitization was assessed by applying a pointed stimulator (pinprick) and calculating the temporal summation. Postoperative stent pain intensity and interference were assessed using PROMIS questionnaires. Data were analyzed using repeated-measures mixed-effects linear models.

RESULTS

Among the 412 participants, the median age was 54.0years, and 46% were female. Higher preoperative pain ratings to 2 kg and 4 kg mechanical pressure to the ipsilateral flank and abdominal areas were associated with higher postoperative stent pain intensity with the stent in situ. Greater degree of central sensitization preoperatively, manifesting as higher temporal summation, was associated with higher postoperative pain intensity. Factors associated with preoperative hypersensitivity on QST included female sex, presence of chronic pain conditions, widespread pain, and depression.

CONCLUSION

Hypersensitivity to pain and central sensitization preoperatively was associated with postoperative ureteral stent pain, suggesting a physiologic basis for stent symptom variation. QST may identify patients more likely to develop stent pain after URS and could inform selection for preventive and interventional strategies.

Nonopioid Pain Management Pathways for Stone Disease

Introduction: New opioid dependency after urologic surgery is a serious adverse outcome that is well-described in the literature. Patients with stone disease often require multiple procedures because of recurrence of disease and hence are at greater risk for repeat opioid exposures. Despite this, opioid prescribing after urologic surgery remains highly variable and in an emergency setting, opioids are still used commonly in management of acute renal colic. Methods: Two literature searches were performed using PubMed. First, we searched available literature concerning opioid-sparing pathways in acute renal colic. Second, we searched available literature for opioid-sparing pathways in ureteroscopy and percutaneous nephrolithotomy (PCNL). Abstracts were reviewed for inclusion in our narrative review. Results: In the setting of acute renal colic, multiple randomized control trials have shown that nonsteroidal anti-inflammatory drugs (NSAIDs) attain greater reduction in pain scores, decreased need for rescue medications, and decreased vomiting events in comparison with opioids. NSAIDs also form a core component in management of postureteroscopy pain and have been demonstrated in randomized trials to have equivalent to improved pain control outcomes compared with opioids. Multiple opioid-free pathways have been described for postureteroscopy analgesia with need for rescue narcotics falling under 20% in most studies, including in patients with ureteral stents. Enhanced Recovery After Surgery protocols after percutaneous nephrolithotomy are less well described but have yielded a reduction in postoperative opioid requirements. Conclusions: In select patients, both acute renal colic and after kidney stone surgery, adequate pain management can usually be obtained with minimal or no opioid medication. NSAIDs form the core of most described opioid-sparing pathways for both ureteroscopy and PCNL, with the contribution of other components to postoperative pain outcomes limited because of lack of head-to-head comparisons. However, medications aimed specifically at targeting stent-related discomfort form a key component of most multimodal postsurgical pain management pathways. Further investigation is needed to develop pathways in patients unable to tolerate NSAIDs.

Can Urinary Stones Change History?

Urolithiasis is a common disorder born with the first hominids and the earliest texts describing symptoms date back to 3200 BC in Mesopotamia. The symptoms have always been the same, whereas the possibility of treatment has changed throughout the history. Gaius Plinius Secondus, known as Pliny the Elder, in his work "Naturalis Historia," described the pain produced by a urinary stone as an excruciating torment. When there was not an effective remedy, could this atrocious torment change the lives and choices of men? When the affected people were kings, powerful, or artists, could renal colic affect their political decisions or their artistic works? I answer positively to these questions. I will set some historical facts to demonstrate this. We will see how the surgical treatment of urolithiasis contributed to separating medicine from surgery in medieval Europe. I will tell how an archer's life was saved by perineal lithotomy surgery. I will try to prove that Michelangelo Buonarroti left traces of his stone disease in the Sistine Ceiling. Finally, I will connect the foundation of Rome, capital of the Kingdom of Italy, to bladder stones. A cultural-scientific game, not a historical treatise, in which I will try to connect some important events to urinary calculi.

[Epidemiology and diagnosis of urinary lithiasis: a cross-sectional study in a Cameroonian based population]

Introduction

urinary stone is a multifactorial disease characterized by the presence of concretions in the urinary tract. The diagnosis of urinary lithiasis is based on clinical and imaging findings. The objective of this study was to determine the profile of patients suffering from urolithiasis in the city of Yaounde.

Methods

this was a descriptive observational cross-sectional study with retrospective data collection. Patients with an age > 15 years and patients diagnosed with lithiasis confirmed by medical imaging were included in our study. The variables studied were sociodemographic, clinical and paraclinical.

Results

a total of 120 patients were included in our study. The mean age was 40.46±12.62 years with extremes from 19 to 74 years. Male gender was predominant at 60.8% (n=73). Renal colic was the circumstance found in 67.5% (n=81). Physical examination was normal in 55.8% (n=67). Insufficient hydration was found in 45% (n=61) of cases. Abdominal scanner was the most performed examination in our study in 50.7% (n=61). The median stone density was 731 Hounsfield units [346; 1183.5]. The stones were predominantly located in the upper tract. The left renal topography was predominant in 35% (n=42) of cases. Urine culture revealed Escherichia Coli at 60% (n=15). Blood calcium, phosphorus and uricemia were requested in 15.8% (n=19), 0.8% (n=1) and 12.5% (n=15) of cases, respectively. The results were normal. In the absence of a laboratory specialized in biochemical analysis of calculi, a minority of patients (n=3) benefited from spectrophotometry.

Conclusion

urinary lithiasis is a disease of men in their forties. Renal colic is the main revealing sign. The diagnosis is revealed by the abdominal scanner in half of the cases. Metabolic assessment and constitutional analysis of the calculus are still very rarely requested.

Did the COVID-19 Pandemic Restrict Access to Emergency Urological Services: Assessment of Reorganisation Effectiveness for Hospital Treatment

Urolithiasis derived renal colic is a common urological condition. If treated properly, the disease resolves without complications; if not treated, it causes infection and renal failure. The COVID-19 restrictions impacted hospitalised treatment of diseases. We analysed the impact of COVID-19 on renal colic treatment at a hospital in Poland. Clinical and demographic data of patients treated during the COVID-19 era were compared with those treated before this pandemic. During the COVID-19 restrictions, renal colic patient hospital admissions fell significantly. However, more patients presented with chronic renal colic symptoms and urinary tract infections. Nevertheless, the degree of hydronephrosis and the number and location of stones did not differ between the two groups. No marked changes were observed in the chosen treatment options. The observed decrease in emergency admissions of patients with acute renal colic with a simultaneous increase in the rate of infectious stones might indicate that some patients requiring urgent medical help did not report to the emergency department or came later than they would before the pandemic, reporting more serious symptoms. One plausible explanation for this may be that the reorganisation of the healthcare system restricted access to urological care. Moreover, some patients may have delayed their visit to the hospital due to the fear of contracting the SARS-CoV-2 coronavirus.

The Erector Spinae Plane Block as Novel Therapy for Renal Colic: A Case Series

We present a 10-patient case series supporting the use of the erector spinae plane block (ESPB) as a novel approach for the treatment of acute pain from renal colic. An in-plane needle approach was used with either transverse or longitudinal orientation of the ultrasound probe on the affected side, in either seated or prone patient position. These cases showed significant improvement in patient reported pain; suggesting that the ESPB can be used safely and effectively for either primary or adjunctive treatment of acute pain due to renal colic in the emergency department.

Comparison Of Emergency And Elective Intervention With Semi-Rigid Ureteroscopic Lithotripsy For Patients With Ureteral Calculi

BACKGROUND

Ureteroscopy (URS) is a safe and highly effective treatment option for treatment of ureteral calculi. With the advancement of technology, there is also expansion of its indications including use in early or emergency setting. This study aims to compare safety and efficacy of emergency ureteroscopy (EmURS) versus elective ureteroscopy (ElURS) for ureteral stones.

METHODS

Patients with unilateral single radio-opaque ureteral stone who underwent semi-rigid URS from January 2008 till December 2019 were included. Patients with solitary kidney, uro-sepsis, pregnancy or pre-operative drainage with nephrostomy or JJ stent were excluded. EmURS was defined as URS being performed within 48 hours of presentation, while ElURS was defined as URS performed after failed medical expulsive therapy. Patient, stone and outcome related variables were compared in both groups. Stone free rate was defined as no evidence of stone on plain x-ray KUB after 1 week.

RESULTS

We compared 132 patients in EmURS group against 264 in ElURS group. Age, gender, comorbidities, stone location, laterality and mean stone size were comparable in both groups. EmURS had a less median operative time (p=0.05). Stone free rate achieved was 90.2% in EmURS and 87.1% in ElURS, respectively (p=0.38). Double J stent was placed in 44.7% and 46.2% of EmURS and ElURS respectively (p=0.89). Ancillary procedures were performed in 9.8% of EmURS and 11.7% of ElURS (p=0.57). Overall complication rates were reported in 7.6% in EmURS and 11.7% in ElURS (p=0.22) and most were Clavien grade 1.

CONCLUSIONS

Emergency URS for ureteral stones is a safe and effective one-stage definitive treatment option for patients with acute renal colic not responding to conservative management.

ACUTE HYDRONEPHROSIS MIMICKING RENAL COLIC

Hydronephrosis may be acute, recurrent and related to ingestion of fluid. Frequently a lower polar vessel is an etiological factor. The condition is amenable to corrective operation by a variety of surgical techniques, as in the six cases here reported.