Opioids in Urology: How Well Are We Preventing Opioid Dependence and How Can We Do Better?
Urologic procedures (both open and minimally invasive) can cause pain due to the surgery itself, devices placed, and post-operative issues. Thus, pain management is important for every post-procedure recovery period. Opioid use post-surgery is common and often over-prescribed contributing to persistent use by patients.
In this article, we review the extent of opioid use in pediatric urologic procedures, vasectomy, endourologic procedures, penile implantation, urogynecologic procedures, prostatectomy, nephrectomy, cystectomy, and scrotal/testicular cancer surgery. Generally, we have found that institutions do not have a standardized protocol with a set regimen to prescribe opioids, resulting in more opioids being prescribed than needed and patients not properly disposing of their unused prescriptions.
However, many institutions recognize their opioid overuse and are implementing new multimodal opioid-sparing analgesics methods such as non-opioid peri-operative medications, minimally invasive robotic surgery, and nerve blocks or local anesthetics with varying degrees of success. By shedding light on these opioid-free methods and prescription protocols, along with improved patient education and counselling, we hope to bring awareness to institutions and decrease unnecessary opioid use.
1. Kiechle JE, Gonzalez CM. The Opioid Crisis and Urology. Urology. 2018;112:27-28.doi:10.1016/j.urology.2017.10.009
2. Koo K, Winoker JS, Patel HD, et al. Evidence-Based Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery. Journal of Endourology. 2021;35(12):1838-1843. doi:10.1089/end.2021.0250
3. Koo K, Faisal F, Gupta N, et al. Recommendations for Opioid Prescribing after Endourological and Minimally Invasive Urological Surgery: An Expert Panel Consensus. Journal of Urology. 2020;203(1):151-158. doi:10.1097/ju.0000000000000514
4. Pekala KR, Jacobs BL, Davies BJ. The Shrinking Grey Zone of Postoperative Narcotics in the Midst of the Opioid Crisis: The No-opioid Urologist. European Urology Focus. 2020;6(6):1168-1169. doi:10.1016/j.eu f.2019.08.014
5. Leapman MS, Kaplan SA. Separating Opioid Fact and Fiction in Urology. Journal of Urology. 2017;198(5):990-992. doi:10.1016/j.juro.2017.08.064
6. Kelley JJ, Hill S, Deem S, Hale NE. Post-Operative Opioid Prescribing Practices and Trends Among Urology Residents in the United States. Cureus. Published online 2020. doi:10.7759/cureus.12014
7. Coughlin JM, Terranella SL, Ritz EM, et al. Understanding Opioid Prescribing Practices of Resident Physicians. American Surgeon. Published online 2022. doi:10.1177/00031348211060412
8. Donnelly L, Feustel PJ, Cangero T, Kogan B. Postoperative pediatric urology opioid prescriptions at a tertiary academic medical center. Journal of Pediatric Urology. 2021;17(5):633.e1-e6. doi:10.1016/j.jpurol.2021.07.006
9. Ahn JJ, Ellison JS, Merguerian PA. A Societies for Pediatric Urology survey of opioid prescribing practices after ambulatory pediatric urology procedures. Journal of Pediatric Urology. 2019;15(5):451-456. doi:10.1016/j.jpurol.2019.04.025
10. Talwar R, Joshi SS. Minimizing opioid consumption following robotic surgery. Transl Androl Urol. 2021;10(5):2289-2296. doi:10.21037/tau.2019.08.11
11. Garren BR, Lawrence MB, McNaull PP, et al. Opioid-prescribing patterns, storage, handling, and disposal in postoperative pediatric urology patients. Journal of Pediatric Urology. 2019;15(3):260.e1-e7. doi:10.1016/j.jpurol.2019.02.009
12. Adler AC, Chandrakantan A, Dang TV, Lee AD, Austin PF. Parental Assessment of Pain Control Following Pediatric Circumcision: Do Opioids Make a Difference? Urology. 2021;154:263-267. doi:10.1016/j.urology.2020.12.027
13. O'Kelly F, Pokarowski M, DeCotiis KN, McDonnell C, Milford K, Koyle MA. Structured opioid-free protocol following outpatient hypospadias repair- A prospective SQUIRE 2.0-compliant quality improvement initiative. Journal of Pediatric Urology. 2020;16(5):647.e1-e9. doi:10.1016/j.jpurol.2020.06.012
14. Nelson R, Shimon T, Grimsby GM. Pediatric Urologic Surgery: Reducing Opioid Use. Pediatr Drugs. 2021;23(5):417-423. doi:10.1007/s40272-021-00462-2
15. Carolan AMC, Parker KM, Grimsby GM. Opioid Use after Pediatric Urologic Surgery: Is It Really Needed? Urology. 2021;158:184-188. doi:10.1016/j.urology.2021.04.012
16. Bilgutay AN, Hua H, Edmond M, et al. Opioid utilization is minimal after outpatient pediatric urologic surgery. Journal of Pediatric Urology. 2020;16(1):108.e1-e7. doi:10.1016/j.jpurol.2019.10.021
17. Doolittle J, Kansal J, Dietrich P, et al. Is Opioid-free Post-Vasectomy Analgesia a Pain? A Single Surgeon Experience. Urology. 2021;154:40-44. doi:10.1016/j.urology.2021.01.050
18. Barham DW, McMann LP, Musser JE, et al. Routine Prescription of Opioids for Post-Vasectomy Pain Control Associated with Persistent Use. J Urol. 2019;202(4):806-810. doi:10.1097/ju.0000000000000304
19. Baker BH, Fox JA, Womble PR, Stromberg IH, Grossgold ET, Walters RC. Optimizing Opioid Pain Medication Use After Vasectomy-A Prospective Study. Urology. 2020;136:41-45. doi:10.1016/j.urology.2019.11.019
20. Awad MA, Sobel DW, Chew BH, Breyer BN, Plante MK, Sternberg KM. Patterns of opioid prescription post ureteroscopy among members of the Endourological Society. Transl Androl Urol. 2021;10(2):851-859. doi:10.21037/tau-20-1121
21. Tam CA, Dauw CA, Ghani KR, et al. New Persistent Opioid Use After Outpatient Ureteroscopy for Upper Tract Stone Treatment. Urology. 2019;134:103-108. doi:10.1016/j.urology.2019.08.042
22. Kang C, Shu X, Herrell SD, Miller NL, Hsi RS. Opiate Exposure and Predictors of Increased Opiate Use After Ureteroscopy. J Endourol. 2019;33(6):480-485. doi:10.1089/end.2018.0796
23. Lee MS, Assmus M, Agarwal D, Rivera ME, Large T, Krambeck AE. Opioid Free Ureteroscopy: What is the True Failure Rate? Urology. 2021;154:89-95. doi:10.1016/j.urology.2021.03.011
24. Sobel DW, Cisu T, Barclay T, Pham A, Callas P, Sternberg K. A Retrospective Review Demonstrating the Feasibility of Discharging Patients Without Opioids After Ureteroscopy and Ureteral Stent Placement. J Endourol. 2018;32(11):1044-1049. doi:10.1089/end.2018.0539
25. Kasman AM, Schmidt B, Spradling K, et al. Postoperative opioid-free ureteroscopy discharge: A quality initiative pilot protocol. Curr Urol. 2021;15(3):176-180. doi:10.1097/cu9.0000000000000025
26. Serna J, Talwar R, Lee DJ. Reducing Opioid Use After Endourologic Procedures. Curr Urol Rep. 2020;21(5):20. doi:10.1007/s11934-020-00975-2
27. Simhan J, Ellis JL, Higgins AM. Pain management strategies in penile implantation. Asian J Androl. 2020;22(1):34-38. doi:10.4103/aja.aja 91 19
28. Ellis JL, Pryor JJ, Mendez M, Sarmiento AS, Perito P, Simhan J. Pain Management Strategies in Contemporary Penile Implant Recipients. Curr Urol Rep. 2021;22(3):17. doi:10.1007/s11934-021-01033-1
29. Dwarica DS, Rubenstein AR, Boccaccio RB, et al. Opioid Pain Medication Use in New Urogynecology Patients. Female Pelvic Med Reconstr Surg. 2020;26(10):622-625. doi:10.1097/spv.0000000000000627
30. Dahl ME, McDonald KC, Brown O, et al. Opioid Consumption After Urogynecologic Surgery: A Prospective Multicenter Observational Study Using a Text-Messaging Survey Tool. Female Pelvic Med Reconstr Surg. 2022; published online ahead of print. doi:10.1097/spv.0000000000001219
31. Linder BJ, Occhino JA, Wiest SR, Klingele CJ, Trabuco EC, Gebhart JB. Assessing the impact of procedure-specific opioid prescribing recommendations on opioid stewardship following pelvic organ prolapse surgery. Am J Obstet Gynecol. 2019;221(5):515.e1-515.e8. doi:10.1016/j.ajog.2019.06.023
32. Reagan KML, Boyles SH, Brueseke TJ, et al. Postoperative Opioid Prescribing After Female Pelvic Medicine and Reconstructive Surgery. Female Pelvic Med Reconstr Surg. 2021;27(11):643-653. doi:10.1097/spv.0000000000001113
33. Solouki S, Vega M, Agalliu I, Abraham NE. Patient Satisfaction and Refill Rates After Decreasing Opioids Prescribed for Urogynecologic Surgery. Female Pelvic Med Reconstr Surg. 2020;26(12):e78-e82. doi:10.1097/spv.0000000000000929
34. Moskowitz D, Amin K, Lucioni A, Kobashi K, Lee U. Opioid Prescription and Use in Sacral Neuromodulation, Mid Urethral Sling and Pelvic Organ Prolapse Surgery: An Educational Intervention to Avoid Over Prescribing. J Urol. 2019;201(5):979-986. doi:10.1097/ju.0000000000000028
35. Zorn KC, Gautam G, Shalhav AL, et al. Training, credentialing, proctoring and medicolegal risks of robotic urological surgery: recommendations of the society of urologic robotic surgeons. Journal of Urology. 2009;182(3):1126-1132. doi:10.1016/j.juro.2009.05.042
36. Yaxley JW, Coughlin GD, Chambers SK, et al. Robot-assisted laparoscopic prostatectomy versus open radical retropubic prostatectomy: early outcomes from a randomised controlled phase 3 study. Lancet. 2016;388(10049):1057-1066. doi:10.1016/s0140-6736(16)30592-x
37. Shkolyar E, Shih IF, Li Y, Wong JA, Liao JC. Robot-Assisted Radical Prostatectomy Associated with Decreased Persistent Postoperative Opioid Use. J Endourol. 2020;34(4):475-481. doi:10.1089/end.2019.0788
38. Prebay ZJ, Medairos R, Landowski T, et al. Pain management following robotic-assisted radical prostatectomy: transitioning to an opioid free regimen. J Robotic Surg. 2021;15(6):923-928. doi:10.1007/s11701-021-01191-x
39. Sawczyn G, Lenfant L, Aminsharifi A, Kim S, Kaouk J. Predictive factors for opioid-free management after robotic radical prostatectomy: the value of the SP® robotic platform. Minerva Urol Nephrol. 2021;73(5):591-599. doi:10.23736/s2724-6051.20.04038-2
40. Hacker EC, Pere MM, Yu M, Gul ZG, Jacobs BL, Davies BJ. Large Variation in International Prescribing Rates of Opioids After Robotic Prostatectomy. Urology. 2022;159:93-99. doi:10.1016/j.urology.2021.10.002
41. Brummett CM, Waljee JF, Goesling J, et al. New Persistent Opioid Use After Minor and Major Surgical Procedures in US Adults. JAMA Surg. 2017;152(6):e170504. doi:10.1001/jamasurg.2017.0504
42. Clarke H, Soneji N, Ko DT, Yun L, Wijeysundera DN. Rates and risk factors for prolonged opioid use after major surgery: population based cohort study. BMJ. 2014;348:g1251. doi:10.1136/bmj.g1251
43. Loeb S, Cazzaniga W, Robinson D, Garmo H, Stattin P. Opioid Use after Radical Prostatectomy: Nationwide, Population Based Study in Sweden. J Urol. 2020;203(1):145-150. doi:10.1097/ju.0000000000000451
44. Theisen KM, Davies BJ. A Radical Proposition: Opioid-sparing Prostatectomy. Eur Urol Focus. 2020;6(2):215-217. doi:10.1016/j.euf.2019.06.011
45. Turcotte B, Jacques E, Tremblay S, Toren P, Caumartin Y, Lodde M. Opioids use after uro-oncologic surgeries in time of opioid crisis. Canadian Urological Association Journal. 2022;16(8). doi:10.5489/cuaj.7633
46. Theisen KM, Myrga JM, Hale N, et al. Excessive Opioid Prescribing After Major Urologic Procedures. Urology. 2019;123:101-107. doi:10.1016/j.urology.2018.06.057
47. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ. 2018;360:j5790. doi:10.1136/bmj.j5790
48. Cheung DC, Martin LJ, Jivraj NK, et al. Opioid Use After Nephrectomy for Kidney Cancer in Ontario: A Population-Based Study. Urology. 2022;164:118-123. doi:10.1016/j.urology.2022.02.002
49. Okoro C, Holt S, Ellison JS, Raskolnikov D, Gore JL. Discharge Opioid Prescription Patterns After Kidney Cancer Surgery. Urology. 2021;153:228-235. doi:10.1016/j.urology.2020.12.047
50. Witjes JA, Bruins HM, Cathomas R, et al. European Association of Urology Guidelines on Muscle-invasive and Metastatic Bladder Cancer: Summary of the 2020 Guidelines. European Urology. 2021;79(1):82-104. doi:10.1016/j.eururo.2020.03.055
51. Shabsigh A, Korets R, Vora KC, et al. Defining early morbidity of radical cystectomy for patients with bladder cancer using a standardized reporting methodology. European Urology. 2009;55(1):164-176. doi:10.1016/j.eururo.2008.07.031
52. Cerantola Y, Valerio M, Persson B, et al. Guidelines for perioperative care after radical cystectomy for bladder cancer: Enhanced Recovery After Surgery (ERAS®) society recommendations. Clinical Nutrition (Edinburgh, Scotland). 2013;32(6):879-887. doi:10.1016/j.clnu.2013.09.014
53. Sharma G, Krishna M, Pareek T, et al. Current practice patterns in the perioperative management of patients undergoing radical cystectomy: Results from a global survey. Urologic Oncology. 2022;40(5):196.e1-196.e9. doi:10.1016/j.urolonc.2022.01.003
54. Miller BL, Abel EJ, Allen G, et al. Trends in epidural anesthesia use at the time of radical cystectomy and its association with perioperative and survival outcomes: a population-based analysis. American Journal of Clinical and Experimental Urology. 2020;8(1):28-37.
55. Patel SY, Ackerman RS, Boulware D, Poch MA. Epidural anesthesia may be associated with increased postoperative complications in the elderly population undergoing radical cystectomy: an analysis from the National Surgical Quality Improvement Project (NSQIP) database. World J Urol. 2020;39(2):433-441. doi:10.1007/s00345-020-03212-0
56. Audenet F, Attalla K, Giordano M, et al. Prospective implementation of a nonopioid protocol for patients undergoing robot-assisted radical cystectomy with extracorporeal urinary diversion. Urologic Oncology. 2019;37(5):300.e17-300.e23. doi:10.1016/j.urolonc.2019.02.002
57. Hicks N, Gupta S. Complications and risk factors in elective benign scrotal surgery. Scandinavian Journal of Urology. 2016;50(6):468-471. doi:10.1080/21681805.2016.1204622
58. Yerram NK, Arora HC, Khanna A, et al. Testicular seminoma: oncologic rationale and role of surgery in treatment. Clinical Advances in Hematology & Oncology. 2017;15(9):708-715.
59. Greer AB, Ramos L, Dubin JM, Ramasamy R. Decreasing postoperative opioid use while managing pain: A prospective study of men who underwent scrotal surgery. BJUI Compass. 2020;1(2):60-63. doi:10.1002/bco2.12
60. Mehta A, Hsiao W, King P, Schlegel PN. Perioperative celecoxib decreases opioid use in patients undergoing testicular surgery: a randomized, double-blind, placebo controlled trial. Journal of Urology. 2013;190(5):1834-1838. doi:10.1016/j.juro.2013.04.058