|Year : 2018 | Volume
| Issue : 2 | Page : 91-94
Efficacy of parecoxib for reducing pyelovenous backflow pain during retrograde intrarenal surgery
Yi-Hao Wu1, Chun-Te Wu1, Cheng-Feng Lin1, Wen-Hsiang Chen1, Shian-Shiang Huang1, Lawrence Shih-Hsin Wu2, Cheng-Chia Lin1
1 Department of Urology, Chang Gung Memorial Hospital, Keelung, Taiwan
2 Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
|Date of Web Publication||30-Apr-2018|
No. 222, Maijin Rd., Anle Dist., Keelung City 204
Source of Support: None, Conflict of Interest: None
Objective: The goal of this paper is to evaluate the safety and efficacy of perioperative parecoxib, a cyclooxygenase-2 inhibitor in reducing transient postoperative pyelovenous backflow pain in patients undergoing retrograde intrarenal surgery (RIRS). Materials and Methods: We instituted a change in our institutional clinical practice starting in January 2016. Since January 2016, all patients undergoing RIRS were administered perioperative intravenous parecoxib. Patients with a history of chronic renal failure (Cr over 2.5) or coronary heart disease did not receive parecoxib. The numerical scale NRS (Numerical rating scale) was recorded after postoperative conscious recovery within 24 h of the postoperative hospitalization. The NRS values were compared with a matched cohort of patients treated with RIRS at our center before January 2016 initiation of parecoxib administration to RIRS patients. Results: A total of 116 patients received Parecoxib during RIRS between January 2016 and August 2016. We found that parecoxib infusion was associated with significantly decreased of NRS. Out of 243 patients, 160 patients treated with parecoxib received an NRS of 1.57 points versus 127 of 243 matched controls who had an NRS of 3.32 points (P < 0.0001). The proportion of NRS >4 score in the patients with parecoxib infusion is much lower than those patients who did not receive Parecoxib (9% vs. 30%). Conclusion: Use of perioperative parecoxib during RIRS is associated with a significant reduction in transient postoperative pyelovenous backflow pain and increased operation quality.
Keywords: Parecoxib, retrograde intrarenal surgery, transient postoperative pyelovenous backflow pain
|How to cite this article:|
Wu YH, Wu CT, Lin CF, Chen WH, Huang SS, Wu LS, Lin CC. Efficacy of parecoxib for reducing pyelovenous backflow pain during retrograde intrarenal surgery. Urol Sci 2018;29:91-4
|How to cite this URL:|
Wu YH, Wu CT, Lin CF, Chen WH, Huang SS, Wu LS, Lin CC. Efficacy of parecoxib for reducing pyelovenous backflow pain during retrograde intrarenal surgery. Urol Sci [serial online] 2018 [cited 2018 May 24];29:91-4. Available from: http://www.e-urol-sci.com/text.asp?2018/29/2/91/228288
| Introduction|| |
Retrograde intrarenal surgery (RIRS) creates a new era for renal stone management. Owing to major improvements in available technology, RIRS has gained wider acceptance, not only as a tool for diagnostic procedures but also for therapeutic approaches to the upper urinary system. Growing experience in conducting RIRS has led to broader applications of this approach, particularly in the treatment of nephrolithiasis. Like other surgical interventions, peri- and postoperative pain are onerous on the patient. Pain has systemic effects throughout the body. These effects include associated psychosocial morbidity and mortality, which can delay recovery from surgery and have physiologically detrimental consequences. In spite of the increased focus on the importance of postoperative pain and the development of medication, the majority of patients still experience acute pain after surgery. Moreover, 86% of these patients have reported that their pain was moderate, severe, or extreme.
Interestingly, we have found a portion of our patients experienced a transient acute flank pain after the operation that do not relate to infection or mucosal maceration. The pain resolved after analgesics are given few hours later. We believe that this pain originates from pyelovenous or pyelolymphatic backflow induced by high-pressure intraoperative irrigation. Preemptive analgesia, a new clinical concept, involves the introduction of an analgesic regimen before the onset of noxious stimuli such as surgical intervention, with the goal of preventing sensitization of the nervous system to subsequent stimuli that could amplify pain. Nonsteroidal anti-inflammatory drugs (NSAIDs) have a significant role in postoperative pain control as they reduce the use of opioids  which are associated with a variety of postoperative side effects such as ventilatory depression, drowsiness and sedation, nausea and vomiting, pruritus, urinary retention, ileus, and constipation. However, the efficacy of NSAIDs for the treatment of pain is due to the inhibition of the cyclooxygenase-2 (COX-2) enzyme. At the same time, the inhibition of the COX-1 enzyme may lead to disturbance of normal platelet function and gastrointestinal toxicity. Selective COX-2 inhibitors offer significantly less gastrointestinal toxicity and no effects on platelet aggregation. We, therefore, postulate that selective COX-2 inhibitors are more suitable for perioperative use. To test this hypothesis, we used parecoxib, a COX-2 selective inhibitor before RIRS to evaluate the efficacy of pyelovenous pain reduction.
| Materials and Methods|| |
Data were collected retrospectively from the medical database of a consecutive series of 243 patients who underwent flexible ureterorenoscopy (FURS) for upper ureter and renal stones at our institution between July 2015 and August 2016. Patients were informed of the benefits and risks of FURS, possible alternative treatments, and the potential need for a staged procedure to achieve satisfactory stone clearance. All patients signed informed consent before the surgery. Inclusion criteria were aged 18–86 years and possessed renal stones ≥0.5 cm in diameter. Exclusion criteria were pregnancy, infection, indications of an obvious mucosal injury, and FURS advance failure cases.
Clinical features and outcome
We reviewed demographic and stone characteristics, outcomes, and complications related to the procedure. Routine perioperative and 1-month postoperative work-up included history, physical examination, urinalysis, urine culture, and blood tests. An abdominal kidney ultrasound, kidney, ureter and bladder radiography, intravenous pyelogram, and computed tomography scan were selectively performed in all cases perioperatively. The stone diameter was defined as the maximum diameter of the biggest one plus one-quarter diameter of the second one, and the others were neglected in multiple renal stone cases. The numeric pain rating scale was recorded after postoperative recovery within 24 h of hospitalization. This value was then compared with a matched cohort of patients treated with RIRS at our center before the initiation of parecoxib administration policy for RIRS.
Patients underwent a RIRS procedure performed with lithotomy position under general anesthesia. Perioperative prophylaxis antibiotic was given intravenously 30 minutes before the procedure. Parecoxib 40mg was given by intravenous administration in controlled group after antibiotics used. RIRS is started after semi-rigid ureteroscope-assisted insertion of a hydrophilic wire, which is confirmed in the correct position by fluoroscopy perioperatively. The extracorporeal contrast was infused for clarifying upper urinary tract anatomy and stone location in selected cases. The RIRS with holmium laser lithotripsy was performed in Ureteral access sheath (COOK ®, 14/12 Fr) for ureter protection. We used an Olympus digital flexible URF-V ureteroscope (Olympus America Inc., Tokyo) for stone manipulation. All patients descripted above were treated by a single surgeon in a single hospital. Any 4.7–6 Fr. Open-end JJ stent placed at the end of the procedure based on the surgeon's discretion was removed approximately 10–28 days postoperatively.
The numeric pain rating scale (NRS) was recorded approximately 4 h after postoperative recovery during hospitalization and compared with that of patients treated with RIRS at our center before the onset of our Parecoxib administration policy. Analysis of the study data was applied using SPSS version 21.0 (IBM Crop. NY USA). P < 0.05 was accepted as statistically significant.
The study protocol conformed to the ethical guidelines of the 1975 Declaration of Helsinki and was approved by the Ethics Committee of Chang Kung Memorial Hospital, Keelung Division.
| Results|| |
Patient and stone characteristics
A total of 116 patients received Parecoxib (Dynastat) and 127 patients not received parecoxib during RIRS between January 2016 and August 2016. The There were no significant differences between the groups with regard to age, gender, stone location, stone size, comorbidities, anesthesia risk, and perioperative renal function [Table 1].
The numerical rating scale (NRS) 10-cm line was used to assess and quantify pain within 24 h after surgical intervention. Postoperative NRS pain score was 1.577 versus 3.32 (P< 0.001) for Dynastat group versus no Dynastat group, respectively. Moreover, we found that the patients without Dynastat group had more postoperative painkiller needed [Table 2]. The proportion of NRS >4 scores in the patients with Dynastat infusion was much lower than those patients without Dynastat infusion [Table 3].
|Table 2: Numerical scale and postoperative analgesics need in patients with and without dynastat|
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| Discussion|| |
The American Society of Anesthesiologists recently released guidelines stating that under-treatment of postoperative pain results in multiple undesirable physiologic and psychological outcomes including pulmonary complications, extended hospital or intensive care unit stay, unplanned readmission, and the development of chronic pain. Therefore, the treatment of acute postoperative pain is an important issue.
Preemptive analgesia is a new strategy of postoperative pain management. The key concept is to prevent the altered sensory processing from the surgical process with medication before the intervention. There are a number of medications been tested for this strategy, including opioids, anesthetic drugs and NSAIDs. However, various side effects have been reported.
NSAIDs are a well-established class of drugs that have long been used for the blockage of pain and inflammation. They can maintain a constant level of prostaglandin inhibition over the course of a prolonged surgery and during the postoperative period, which helps reduce opioid requirement and the potential over-prescription of opiate. Selective COX-2 inhibitors have the advantage over nonselective COX inhibitors of not increasing the risk of platelet inhibition, therefore, decreasing the risk of bleeding and GI ulceration. However, they have an increased risk of myocardial infarction and cardiovascular derangements along with thromboembolic phenomenon. Parecoxib is an intravenously injectable selective COX-2 inhibitor with a safe cardiovascular profile. It is a prodrug (the parent drug is inactive) that is rapidly hydrolyzedin vivo to its active form, valdecoxib. Clinical trials have shown that parecoxib is effective in treating postoperative pain resulting from oral surgery, orthopedic surgery and abdominal hysterectomy pain.
Unlike conventional surgical intervention, which is categorized as intermediate or major level, RIRS is a natural orifice transluminal endoscopic surgery. This categorizes RIRS as minor level. As a flexible ureteroscope advances from the urethra to the renal pelvis, intrarenal pressure increased. The high intrarenal pressure potentially leads to retroperitoneal extravasation and pyelovenous backflow, which result in flattening of the urothelium, submucosal edema, and congestion occur, followed by vasculitis, tubular vacuolization, and focal renal scarring. We believe that postoperative pain related to RIRS is a result of de novo infection, urothelial wall extravasation, and high-pressure irrigation-induced pyelovenous backflow. After excluding infection and mucosal injury, we found that Parecoxib is able to reduce the transient pyelovenous backflow pain during RIRS, especially the high NRS group.
| Conclusion|| |
Perioperative Parecoxib use during RIRS was associated with a significant reduction in transient postoperative pain induced by pyelovenous backflow, especially in NRS above 4 groups. Therefore, it provides the patient with better operative quality and satisfaction.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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[Table 1], [Table 2], [Table 3]