Micro Blog Articles by Henry Rosevear, MD

The American Urological Association recently held its national meeting in Chicago and I had the privilege of attending.

While there were countless fascinating and thought provoking presentations and abstracts, this one was my favorite. It shows a novel method to minimize narcotic use following ureteroscopy.

Enhanced Recovery After Surgery Protocol for Ureteroscopy: A Prospective Comparative Study Evaluating A No Opioid vs Standard Protocol.

Presentation Authors: Chad Gridley*, Jennifer Robles, Joshua Calvert, Nicholas Kavoussi, Taylor Winkler, Jennifer Jayaram, Matthew Fosnot, Justin Liberman, Brian Allen, Matthew McEvoy, Duke Herrell, Ryan Hsi, Nicole Miller, Nashville, TN

Introduction: Nephrolithiasis patients undergoing ureteroscopy are at risk for opioid dependence due to the nature of the disease, multiple provider encounters across an acute episode, and surgical and stent-related pain. The objective of this study was to evaluate an Enhanced Recovery After Surgery (ERAS) care pathway that provides standardization for the anesthetic care and post-operative management of patients undergoing ureteroscopy and stent placement with a goal towards minimizing opioid exposure.

Methods: Consecutive patients undergoing ureteroscopy and stent placement were identified leading up to and after implementation of the ERAS protocol. Urinary symptoms, pain, and PROMIS survey scores were obtained before surgery. The ERAS protocol included preoperative non-opioid premedication, minimal intraoperative and post-anesthesia opioids, and explicitly written non-opioid discharge medications. Patients were contacted at 48-72 hours and seven days postop to obtain follow up survey scores. Unanticipated phone calls, emergency room visits, and need for opioid refills were obtained. Collected data was compared between the two study populations.

Results: Among 53 patients enrolled (29 pre-intervention, 24 ERAS), mean age was 54.2 years and 57% were women. There was no difference in gender or age between the groups. On univariate and multivariable analyses, there were no significant differences between preoperative and postoperative survey results (Figure 1). The difference in morphine equivalent dosages was significant (p < 0.001). There were no significant differences seen between pre- or post-ERAS groups for additional opioid requests, unexpected patient phone calls, or emergency room visits.

Conclusions: Implementation of this ERAS protocol for patients undergoing ureteroscopy and ureteral stenting resulted in reduction to almost near-zero levels of opioid prescribing with fewer post-operative phone calls and no adverse effect on patient reported outcomes, emergency room visits, or opioid refills.

Not too long ago, surgeons during their training routinely worked over 100 hours a week; there is a reason they were call “house” officers.  

After a tragic incident in 1984 many programs changed to mandatory work hours which limited the amount of time residents could spend in the hospital.  And while it intuitively makes sense that if residents work fewer hours, they will be safer, there was no data that actually supported that concept. In fact, given that the reduction on work hours would necessarily create additional hand offs between on coming and off going residents, some people even hypothesized that reducing work hours would decrease patient safety.  Further, there was a concern that by reducing work hours residency programs would produce less experienced physicians.

Almost thirty years later, the first study that actually looked at the effect of resident work hours on patient safety was just produced in the New England Journal of Medicine (here). 

And the results?  It doesn’t matter.  There appears to be no effect on patient safety based on resident work hours.  The study did not look at the effect of work hours on resident preparation for the real world so the debate will likely continue…

The fact that smoking kills people is well known. Smoking is the direct cause of 1 in 5 deaths in America. Smoking costs the American healthcare system over 300 Billion dollars a year in direct costs. Smoking is bad for you.

Until recently, Americans seemed to be getting the message.  In 2005, 21% of Americans were smokers and in 2017 the number had dropped to 14%.  Way to go America.  But then along came e-cigarettes and vaping and now we’re losing the battle again.

E-cigarettes are electronic devices, some as small as a USB drive, that heat nicotine combine it with flavoring and deliver the product as an aerosol spray to the user. While there is some data that supports the concept that e-cigarettes are better for a person’s health than cigarette smoking, there is NO data that e-cigarette smoking is healthy. Quite the contrary, compared to not smoking at all, there is an incredible amount of data that says that e-cigarettes are dangerous. Nicotine is still highly addictive and has been proven to cause brain damage especially in people under 25.  

And therein lies the problem. 

The manufacturers of these e-cigarette products are actively targeting young people though the use of clever social media advertising and the addition of flavoring such as fruit medley, mango and mint.  Further, the FDA has allowed on line sales of these products with minimal oversight. This is a healthcare disaster and needs to be quickly addressed.

But the solution is not simple; and anyone who says otherwise is wrong.  If an adult current smoker can use an e-cigarette product to transition away from cigarette smoking with the eventual goal of quitting entirely, e-cigarettes are a good thing.  If a child or young adult is hooked on nicotine and suffers irreversible brain damage by using e-cigarettes, that is bad.

Patients, parents, health care providers and politicians need to be fully aware of the massive healthcare risks associated with these products.  Simply raising the age when someone can buy these products while appealing in its simplicity is not the correct answer. Numerous studies have shown that age limits do not change behavior, in fact, there is some data that says raising the legal age to buy cigarettes actually increases the “cool” factor of cigarettes and increases underage usage. Rather steps such as banning flavoring combined with strict rules on advertising and a strong public education push have been shown to help reduce smoking and prevent young adults from ever starting to use these very dangerous products.No one likes being lectured; I understand that.  But as America continues to struggle with how to pay for our massively expensive healthcare system we need to be aware of the numerous ways that we are increasing the costs of healthcare through completely preventable diseases. Not only would America be healthier if no one smoked, just think of what America could do with the 300 billion dollars a year we would save.  

“On April 16, 2019 the FDA ordered all manufacturers of surgical mesh intended for transvaginal repair of anterior compartment prolapse (cystocele) to stop selling and distributing their products immediately.” The full FDA report can be found here.

This is the just the next step in a long and ongoing process as the FDA evaluate the use of surgical mesh. Mesh in urological surgery is commonly used for three conditions:

-transvaginal mesh for pelvic organ prolapse

-transabdominal mesh for pelvic organ prolapse

-mesh sling to treat stress urinary incontinence

It is important to note that the recent FDA order only applies to the use of transvaginal mesh for pelvic organ prolapse and does not in any way change our practice of using mesh in other FDA situations. Further it should be noted that the FDA states that “Women who have received transvaginal mesh for the surgical repair of pelvic organ prolapse should continue with their annual and other routine check-ups and follow up care.  There is no need to take additional action.”

I realize that not only are the treatment options available for the treatment of pelvic organ prolapse confusing but the recent FDA announcement further muddies the situation. While I do not treat pelvic organ prolapse in my surgical practice, I have numerous partners who are skilled in all of the treatment options available and if any patient has questions regarding their options, please contact my office for a consultation.

There is an opioid crisis in America; of that no one disagrees.  The reasons for the crisis on the other hand are hotly debated.

I was speaking at the Rocky Mountain Urological Society’s annual meeting recently and the lecturer who followed me was Dr. Nicole Miller of Vanderbilt University.  Dr. Miller is an incredible lecturer and one of America’s foremost kidney stone experts.  She gave a talk about post ureteroscopy pain control that changed my practice.

Surgery hurts; and surgeons are not sadists. As a result, I was trained to prescribe narcotics in the immediate post-operative period. Dr. Miller presented unequivocal data that narcotics do not help control post-ureteroscopy pain.

Think about that for a moment.  What a generation of doctors has been doing in an honest effort to help their patients has been wrong.

It turns out that in the post-ureteroscopy setting, a combination of Tylenol, ibuprofen, Tamsulosin and oxybutynin is all that it takes. 

Further it turns out that 1/10 patients who are given narcotics for post-operative pain become addicted to the medications. As a result, I intend to immediately change my practice to dramatically limit the narcotics that I prescribe in the post-ureteroscopy setting and will highly encourage all of my colleagues to do the same.