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To assess longitudinal prescribing patterns for patients undergoing urologic surgery in the nearly 2-year time frame before and after implementation of an evidence-based opioid prescribing guideline to accurately characterize the impact on postoperative departmental practices.Historical prescribing data for adults who underwent 21 urologic procedures at 3 academic institutions were used to derive a 4-tiered guideline for postoperative opioid prescribing. The guideline was implemented on January 16, 2018, and prescribing patterns including quantity of opioids prescribed (in oral morphine equivalents [OMEs]) and refill rates were compared for opioid-naïve patients undergoing urologic surgery before (January 1, 2016, through January 15, 2018; N=10,649) and after (January 16, 2018, through September 30, 2019; N=9422) guideline implementation. Univariate analysis was performed using Wilcoxon rank sum and χThe median quantity of opioids decreased from 150 OMEs (interquartile range, 0-225) before guideline implementation to 0 OMEs (interquartile range, 0-90) after guideline implementation (P.001). Median OMEs decreased significantly in each tier and each of 21 individual procedures. Overall guideline adherence was 90.7% (n=8547). Despite this decrease in OMEs prescribed, post-guideline implementation patients obtained fewer refills than the pre-guideline implementation group (614 [6.5%] vs 999 [9.4%]; P.001).In a multi-institutional follow-up prospective study of adult urologic surgery-specific evidence-based guidelines for postoperative prescribing, we demonstrate sustained reduction in OMEs prescribed secondary to guideline implementation and adherence by our providers.

We developed evidence-based guidelines for postoperative opioid prescribing after urologic surgery and assessed changes in prescribing after implementation.Prescribing data for adults who underwent 21 urologic procedures were used to derive a four-tiered guideline for postoperative opioid prescribing. This was implemented on January 1, 2018, and prescribing patterns including quantity of opioids prescribed (oral morphine equivalents; OME) and refill rates were compared between patients undergoing surgery prior to (January-April, 2017; n equals 1732) and after (January-April, 2018; n equals1376) implementation.The median OME (IQR) prescribed was significantly lower for 2018 compared with 2017 [100 (0; 175) versus 150 (60; 225); p .0001]. The median prescribed OME decreased in 14/21 procedures (67%). The refill rates did not significantly change. Guideline adherence rates after implementation, based on individual procedures, ranged from 33 to 95%.Fewer opioids were prescribed after implementing a prescribing guideline. Additional study is required to assess patient opioid utilization.

Our goal was to evaluate long-term safety and durability of response to UGN-101, a mitomycin-containing reverse thermal gel, as primary chemoablative treatment for low-grade upper tract urothelial carcinoma.In this open-label, single-arm, multicenter, phase 3 trial (NCT02793128), patients ≥18 years of age with primary or recurrent biopsy-proven low-grade upper tract urothelial carcinoma received 6 once-weekly instillations of UGN-101 via retrograde catheter to the renal pelvis and calyces. Those with complete response (defined as negative ureteroscopic evaluation, negative cytology and negative for-cause biopsy) 4-6 weeks after the last instillation were eligible for up to 11 monthly maintenance instillations and were followed for ≥12 months with quarterly evaluation of response durability. Durability of complete response was determined by ureteroscopic evaluation; duration of response was estimated by the Kaplan-Meier method. Treatment-emergent adverse events (TEAEs) were monitored.Of 71 patients who initiated treatment, 41 (58%) had complete response to induction therapy and consented to long-term followup; 23/41 patients (56%) remained in complete response after 12 months (95% CI 40, 72), comprising 6/12 (50%) who did not receive any maintenance instillations and 17/29 (59%) who received ≥1 maintenance instillation. Kaplan-Meier analysis of durability was estimated as 82% (95% CI 66, 91) at 12 months. Ureteric stenosis was the most frequently reported TEAE (31/71, 44%); an increasing number of instillations appeared to be associated with increased incidence of urinary TEAEs.Durability of response to UGN-101 with or without maintenance treatment is clinically meaningful, offering a kidney-sparing therapeutic alternative for patients with low-grade disease.

INTRODUCTION AND OBJECTIVE:Standard treatment for low-grade upper tract urothelial carcinoma (LG UTUC) involving the renal pelvis and calyces is radical nephroureterectomy (RNU), or nephron-sparing...

INTRODUCTION AND OBJECTIVE:Urothelial cancer is less common, but may be associated with poorer outcomes in women than in men. The literature on gender-based differences in low-grade upper tract uro...

INTRODUCTION AND OBJECTIVE:Morcellation is the most common tool used to remove adenoma from the bladder after prostate enucleation. Morcellators are relatively expensive and are not available at ev...

Objective To describe postoperative opioid prescribing practices in a large cohort of patients undergoing urological surgery. Patients and Methods We identified 11,829 patients who underwent 21 urological surgical procedures at 3 associated facilities from January 1, 2015, through December 31, 2016. After converting opioids to oral morphine equivalents (OMEs), prescribing patterns were compared within and across procedures. Subgroup analysis for opioid-naive patients (those without a history of long-term opioid use) was performed. Statistical analysis was utilized to evaluate variations based on demographic and perioperative/postoperative variables. Results Of the 11,829 patients, 9229 (78.0%) were prescribed an opioid at discharge, and the median (interquartile range [IQR]) OME prescribed was 188 (150-225). The remaining 9253 patients (78.2%) were considered opioid naive. Striking variation in prescribing patterns was observed within and across surgical procedures. For instance, IQR ranges of 150 or greater were observed for open cystectomy (median, 300; IQR, 210-375], open radical nephrectomy (median, 300; IQR, 225-375), retroperitoneal node dissection (median, 300; IQR, 225-375), hand-assisted laparoscopic nephrectomy (median, 225; IQR, 150-300), and penile prosthesis (median, 225; IQR, 150-315). On multivariate analysis, younger age, cancer diagnosis, and inpatient hospitalization were associated with higher likelihood of receiving a highest-quartile OME prescription for opioid naive patients. Thirty-day refill rates varied from 1.6% to 25.9%. Interestingly, refill rates were higher in patients receiving more opioids at discharge. Conclusion The United States is facing an opioid epidemic, and physicians must take action. In this study, we found considerable variation in opioid prescribing patterns within and across surgical procedures. These data provide support for the development of standardized opioid prescribing guidelines for postoperative analgesia.

Most patients with low-grade upper tract urothelial cancer are treated by radical nephroureterectomy. We aimed to assess the safety and activity of a non-surgical treatment using instillation of UGN-101, a mitomycin-containing reverse thermal gel.In this open-label, single-arm, phase 3 trial, participants were recruited from 24 academic sites in the USA and Israel. Patients (aged ≥18 years) with primary or recurrent biopsy-proven, low-grade upper tract urothelial cancer (measuring 5-15 mm in maximum diameter) and an Eastern Cooperative Oncology Group performance status score of less than 3 (Karnofsky Performance Status score40) were registered to receive six instillations of once-weekly UGN-101 (mitomycin 4 mg per mL; dosed according to volume of patient's renal pelvis and calyces, maximum 60 mg per instillation) via retrograde catheter to the renal pelvis and calyces. All patients had a planned primary disease evaluation 4-6 weeks after the completion of initial therapy, in which the primary outcome of complete response was assessed, defined as negative 3-month ureteroscopic evaluation, negative cytology, and negative for-cause biopsy. Activity (complete response, expected to occur in15% of patients) and safety were assessed by the investigator in all patients who received at least one dose of UGN-101. Data presented are from the data cutoff on May 22, 2019. This study is registered with ClinicalTrials.gov, NCT02793128.Between April 6, 2017, and Nov 26, 2018, 71 (96%) of 74 enrolled patients received at least one dose of UGN-101. 42 (59%, 95% CI 47-71; p0·0001) patients had a complete response at the primary disease evaluation visit. The median follow-up for patients with a complete response was 11·0 months (IQR 5·1-12·4). The most frequently reported all-cause adverse events were ureteric stenosis in 31 (44%) of 71 patients, urinary tract infection in 23 (32%), haematuria in 22 (31%), flank pain in 21 (30%), and nausea in 17 (24%). 19 (27%) of 71 patients had study drug-related or procedure-related serious adverse events. No deaths were regarded as related to treatment.Primary chemoablation of low-grade upper tract urothelial cancer with intracavitary UGN-101 results in clinically significant disease eradication and might offer a kidney-sparing treatment alternative for these patients.UroGen Pharma.

INTRODUCTION AND OBJECTIVE:Ureteroscopy (URS) for the management of kidney and ureteral stones utilizes a variety of disposables which can account for a significant portion of the cost of care. We ...

INTRODUCTION AND OBJECTIVES:Previous work has identified disconnect between opioid prescribing and utilization. This is particularly relevant for minimally-invasive surgery. However, factors that c...

INTRODUCTION AND OBJECTIVES:Only 30% of UTUC patients receive endoscopic, nephron-sparing treatments due to (1) high grade histology, (2) tumor burden, or (3) unfavorable tumor location. Endoscopic...

INTRODUCTION AND OBJECTIVES:The United States faces an opioid epidemic, and surgeons must take action. However, a one-size fits all approach to opioid prescribing is sub-optimal. Here, we sought to...

Endourology has evolved rapidly for the management of both benign and malignant disease of the upper urinary tract. Limited data exist, however, on the occupational hazards posed by complex endourologic procedures. The aim of this study was to determine the prevalence and possible causes of hand problems among endourologists who routinely perform flexible ureteroscopy compared with controls.An online computer survey targeted members of the Endourological Society and psychiatrists in academic and community settings. A total of 600 endourologists and 578 psychiatrists were contacted by e-mail. Invited physicians were queried regarding their practice settings and symptoms of hand pain, neuropathy, and/or discomfort.Survey responses were obtained from 122 (20.3%) endourologists and 74 (12.8%) psychiatrists. Of endourologists, 61% were in an academic setting and 70% devoted their practice to endourology. Endourologists were in practice for a mean 13 years, performing 4.5 ureteroscopic cases per week with a mean operative time of 50 minutes. Hand/wrist problems were reported by 39 (32%) endourologists compared with 14 (19%) psychiatrists (P=0.0486, relative risk [RR]=1.69). Surgeons who preferred counterintuitive ureteroscope deflection were significantly more likely to have problems (56%) compared with intuitive users (27%) (RR 2.07, P=0.0139) or those with no preference (26%) (RR 2.15, P=0.0451). Overall, most respondents (85%) with hand/wrist problems needed either medical or surgical intervention.Hand and wrist problems are very common among endourologists. Future studies are needed to develop more ergonomic platforms and thereby reduce the endourologist's exposure to these occupational hazards.

Although there are empiric data to show that obesity is not a contraindication for laparoscopic radical nephrectomy, similar data are lacking for the use of hand-assisted laparoscopic radical nephrectomy (HALRN) in obese patients. We evaluate whether obese patients undergoing HALRN to manage a renal mass are more likely than nonobese patients to experience poor intraoperative and perioperative outcomes.Between June 1, 1999, and May 31, 2006, 150 patients underwent HALRN for the management of a solid renal mass at our institution. We abstracted detailed demographic, clinical, and follow-up data on all patients in this cohort. As our primary analysis, we evaluated associations between body mass index (BMI) and estimated blood loss, operative time, length of stay, and complications using linear and logistic regression models.There was no evidence that obese patients experienced a statistically significant or clinically relevant increase in blood loss (P = 0.97), operative times (P = 0.87) or length of stay (P = 0.62) compared with persons of normal weight. In contrast, although there was no evidence of a linear trend toward complications in patients with a higher BMI (P = 0.19), obese patients were almost three times more likely to experience a complication compared with normal-weight persons (odds ratio: 2.88; 95% confidence interval: 1.01-8.16). Adjusting for relevant clinical covariates individually did not markedly alter these associations.Obesity is not a contraindication for HALRN to manage a renal mass; however, obese patients should be aware that they may be at increased risk for certain complications after surgery, notably ileus and incisional hernias.

Dextranomer/hyaluronic acid copolymer (Zuidex) is currently under Food and Drug Administration investigation for use as a transurethral bulking agent to treat female stress urinary incontinence secondary to intrinsic sphincter deficiency. Urethral obstruction is a recognized complication of bulking agents. We describe an aspiration method to address iatrogenic voiding dysfunction resulting from this therapy.

The mainstay of pharmacologic treatment of overactive bladder is anticholinergic therapy. Cholinergic blockade is efficacious in decreasing the symptoms of urgency, frequency, and urge incontinence, but also is associated with undesirable side effects such as dry mouth, blurred vision, constipation, and central nervous system side effects. The property of anticholinergic agents that has been associated with increased efficacy and tolerability is receptor specificity. The safety of anticholinergic agents has been associated with the pharmacokinetics, metabolism, protein binding, and ability to penetrate the blood brain barrier. Trospium chloride, available in Europe for more than 20 years and under review by the US Food and Drug Administration for the treatment of overactive bladder, is a quaternary amine that is minimally metabolized, not highly protein-bound, and theoretically should not cross the blood brain barrier. Some of the characteristics of this unique anticholinergic agent are reviewed in this article and the relative contributions of these factors are discussed.

Sexual dysfunction and more specifically erectile dysfunction (ED) can be a harbinger of serious occult medical conditions. ED can be considered a clinical manifestation of generalized vascular disease and therefore shares similar risk factors: aging, hypertension, diabetes mellitus, hypercholesterolemia and smoking. The initial evaluation of men with ED should be thorough. Studies of normal and abnormal penile tumescence have led to the discovery of many important pathways. The greatest medical advance in the management of male sexual dysfunction since the identification of androgens have been the discoveries that nitric oxide (NO) is the primary neuro-modulator of penile smooth muscle relaxation and that oral phosphodiesterase type 5 inhibitors enhance erection quality through the NO mechanism. As a consequence of oral pharmacotherapies, the role of invasive diagnostics has diminished. Most guidelines recommend only history, physical exam and limited laboratory testing prior to instituting oral therapies for ED. In 2006 we still have unanswered questions about ED and these will frame the role of future diagnosis and therapy: can lifestyle changes alone improve erectile function; is ED a marker for the development of atherosclerotic heart disease, do lower urinary tract symptoms of benign prostatic hypertrophy and ED share a common pathway?