Brian R. Matlaga, MD, MPH

 Editorial Council, is professor of urology at Johns Hopkins University School of Medicine, Baltimore.

Managing patient pain following stone treatment can be challenging. The genesis of the pain can be multifactorial, and often there is no single, curative agent that the treating urologist can rely on.

In recent years, our urologic community has recognized the drawbacks of relying on opioid agents to manage patient pain. The United States is currently suffering from an opioid epidemic. Although there are likely multiple factors responsible for this situation, physician prescribing patterns may be causative and can continue to exacerbate the problem.

Presently, discussions on pharmacologic management of patient pain are moving toward narcotic-free endoscopic stone procedures. At the same time, there is increasing interest in understanding the patient perception of treatment outcomes. Indeed, patient-reported metrics are an important factor that should be considered in defining a treatment’s success. In particular, when it comes to managing patient pain, the patient’s perspective is particularly relevant.

a group from the University of North Carolina, under the direction of Dr. Davis Viprakasit, 

 how patients suffering from a symptomatic stone event evaluated their treatment outcomes. One of the areas of focus in this investigation was to identify differences in patient-reported outcomes between those who did or did not rank pain control as extremely important.

Pain-focused patients in the study required a larger reduction in symptoms to meet their outcome criteria for desired, expected, and success levels of pain symptoms. By contrast, patients who were not pain focused expected and were willing to accept lower levels of symptom improvement to consider their treatment successful. Patients who rated pain as their primary criteria for treatment success were significantly less likely to reach their expected outcome level for pain, and overall, those patients who were pain focused were less likely to meet their defined success criteria.

This work is important to our field, because it represents an effort to personalize treatment approaches to particular patients’ needs. As with all things in medicine, one size does not fit all. Although non-narcotic pain management should be our aspirational goal, it may not be feasible for every single patient that we treat. Pain management is a complex endeavor.

As urologists evolve our pain management strategies for stone patients, we must understand how patient biases and perceptions can affect the assessment of their treatment outcome. In this way, we will be able to develop novel interventions, be they in the domains of education, communication, or otherwise, which will allow pain to be managed and mitigated in a safe and effective manner.

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"This work is important to our field, because it represents an effort to personalize treatment approaches to particular patients’ needs," writes Brian R. Matlaga, MD, MPH.

Study of stone pain stresses personalized treatment

 Editorial Council, is professor of urology at the James Buchanan Brady Urological Institute, Johns Hopkins Medical Institutions, Baltimore.

The concept of “surgical quality” is emerging as an important component of health care delivery. At present, though, there is no universally accepted definition of what surgical quality is; indeed, this term may mean different things to different physicians, patients, and others.

A variety of efforts have been made to identify specific quality indicators that can be applied to the delivery of surgical care. One of the metrics utilized in a number of studies is the rate of readmission following a surgical intervention. Although there exists uncertainty as to how efforts to reduce hospital readmissions may affect public health, due to their easy-to-track nature, hospital readmission rates will likely remain a quality metric of interest for the foreseeable future. 

As urologists, it is important that we understand factors that can affect hospital readmissions. Due to the prevalence of the condition, an increase in readmission rates associated with kidney stone procedures may account for a large burden on the health care system. Although some readmissions may be medically necessary and not preventable, it may be that certain maneuvers can reduce the likelihood of other readmission scenarios.

features a discussion of the Reducing Operative Complications from Kidney Stones (ROCKS) effort from the University of Michigan group (see article 

 This study provides the practicing urologist with a number of instructive lessons.

Tolterodine pretreatment does not improve stent symptoms

In the ROCKS study, Dr. Ghani and colleagues evaluated patients who underwent ureteroscopy (URS) and assessed factors associated with emergency department visits following the procedure. They found approximately 10% of patients who undergo URS will visit an ED within 30 days of the procedure, and most of these encounters are related to stent symptoms and pain. The great value of the ROCKS study is that it identifies potential areas in which care can be improved.

One need identified in the ROCKS study is an opportunity to better manage stent-related symptoms. However, given the present opioid crisis in the United States, it is important to look for ways to address this problem in a manner that does not rely on simply providing additional narcotic agents for pain control. The ROCKS team assessed that improving the educational materials provided to patients undergoing URS would better prepare them for symptoms associated with ureteral stents. 

A patient who has a better understanding of what post-URS stent symptoms may be expected, and how they may be mitigated, should have a better experience than a patient who is unprepared for such symptoms. It will be exciting to see if this is borne out in future studies.

"The concept of 'surgical quality' is emerging as an important component of health care delivery. At present, though, there is no universally accepted definition of what surgical quality is; indeed, this term may mean different things to different physicians, patients, and others," writes Brian R. Matlaga, MD, MPH.

ROCKS study takes big initial step in improving care

In the current health care environment, increasing emphasis is placed on metrics that capture the quality of care. In the field of stone management, it is challenging both to track certain intuitively obvious quality markers, such as stone-free rates, and to define a method for the differentiation of other more subtle markers of quality such as a planned, staged treatment versus an unnecessary retreatment.

Therefore, quality metrics often focus on simpler-to-track measures such as the unplanned utilization of health care services in the postoperative period. Broadly, such services come in different forms; among the most frequently discussed are unplanned readmissions or emergency department utilization. However, the health care system can also be utilized in ways that are not hospital based, such as interactions with the medical office. Although the latter may not have a direct and easily determined cost associated with it, as an emergency department visit or hospital admission would, it is nonetheless an important quality metric.

In general, one would expect that patients undergoing stone treatment would have low rates of unplanned health care utilization. Du and associates from Washington University have very nicely investigated factors affecting readmission following ureteroscopic stone management (page 4). They found that unplanned encounters were actually fairly common following ureteroscopy. Over one-fourth of patients initiated phone contact with the physician’s office and almost 15% ultimately presented to the emergency department, with 5% being readmitted.

Ultimately, their analysis revealed that inadequate pain control, presence of a ureteral stent, and a first-time stone treatment were the most common reasons for unplanned utilization of health care services.

This study speaks to two important points: optimizing pain management following ureteroscopic procedures and managing patient expectations following their stone removal procedure. As all urologists know, stents are painful. At present, an optimal regimen of pain control has not been universally accepted; various medications, including narcotics, alpha-blockers, anticholinergics, antibiotics, and benzodiazepines are all utilized, but the evidence of their effectiveness is conflicting. Therefore, further study of this area is important.

However, this study also identified another important area to focus on: preparation of the patient for the symptoms of a ureteral stent following ureteroscopy, which urologists may not be doing as well as we should.

A recent study "revealed that inadequate pain control, presence of a ureteral stent, and a first-time stone treatment were the most common reasons for unplanned utilization of health care services [following ureteroscopy]," writes Brian R. Matlaga, MD, MPH.

Quality of stone care: We can do better

	Increasingly, urologists are faced with patients who cannot safely discontinue anticoagulation or antiplatelet medications, even in the face of an impending surgical procedure. This is a trend that is likely to continue into the foreseeable future.

Anticoagulant use in URS patients ups bleeding risk

	When it comes to stone management, such a situation eliminates certain treatment options-percutaneous nephrolithotomy and shock wave lithotripsy-as they cannot be safely performed on an anticoagulated patient. As a result, for the anticoagulated patient with a symptomatic stone requiring treatment, surgical therapy is limited to ureteroscopy (URS).

	This approach is codified in the recently released AUA Surgical Management of Stones Guidelines, which specifically address the issue of stone management in patients who have a bleeding diathesis or require continuous anticoagulation or antiplatelet therapy. The guideline panel’s recommendation was that URS be considered first-line therapy for such patients.

	Importantly, the panel recognized that there can be an increased risk of bleeding associated with URS in this situation; to that end, the guidelines suggest several maneuvers that the urologist may undertake to minimize such risk. These maneuvers include measures to minimize intra-renal pressures by utilizing an access sheath, employing non-pressurized irrigation, and keeping the bladder decompressed with a small catheter if an access sheath is not used.

	The present study by Ingimarsson and colleagues advances our understanding of URS in an anticoagulated setting (see article 

 and builds on a similar series reported by Elkoushy and associates 

). These findings are particularly important, as they provide a broader understanding of the increased risk encountered in this setting.

	One of the most important things that we do as surgeons is to educate our patients on what to expect following a surgical procedure. In this case, we can leverage the findings reported in this study in order to provide more informed counsel to this unique group of patients.

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"Increasingly, urologists are faced with patients who cannot safely discontinue anticoagulation or antiplatelet medications, even in the face of an impending surgical procedure. This is a trend that is likely to continue into the foreseeable future," writes Brian R. Matlaga, MD, MPH.

Brian R. Matlaga, MD, MPH

Articles

Study of stone pain stresses personalized treatment

ROCKS study takes big initial step in improving care

Quality of stone care: We can do better

Use new data to inform unique patient group