SKOPE—Study of Ketorolac vs Opioid for Pain after Endoscopy: A Double-Blinded Randomized Control Trial in Patients Undergoing Ureteroscopy

Abstract

Purpose: Pain is the leading cause of unplanned emergency department visits and readmissions after ureteroscopy, making postoperative analgesic stewardship a priority given the current opioid epidemic. We conducted a double-blinded, randomized controlled trial, with noninferiority design, comparing nonsteroidal anti-inflammatory drugs to opiates for postoperative pain control in patients undergoing ureteroscopy for urolithiasis. Materials and Methods: Patients were randomized and blinded to either oxycodone (5 mg) or ketorolac (10 mg), taken as needed, with 3 nonblinded oxycodone rescue pills for breakthrough pain. Primary study outcome was visual analogue scale pain score on postoperative days 1e5. Secondary outcomes included medication utilization, side effects, and Ureteral Stent Symptom Questionnaire scores. Results: A total of 81 patients were included (43 oxycodone, 38 ketorolac). The 2 groups had comparable patient, stone, and perioperative characteristics. No differences were found in postoperative pain scores, study medication or rescue pill usage, or side effects. Higher maximum pain scores on days 1e5 (p <0.05) and higher questionnaire score (28.1 vs 21.7, p[0.045) correlated with analgesic usage, irrespective of treatment group. Patients receiving ketorolac reported significantly fewer days confined to bed (meanAESD 1.3AE1.3 vs 2.3AE2.6, p[0.02). There was no difference in unscheduled postoperative physician encounters. Conclusions: This is the first double-blinded randomized controlled trial comparing nonsteroidal anti-inflammatory drugs and opiates post-ureteroscopy, and demonstrates noninferiority of nonsteroidal anti-inflammatory drugs in pain control with similar efficacy, safety profile, physician contact and notably, earlier convalescence compared to the opioid group. This provides strong evidence against routine opioid use post-ureteroscopy, justifying continued investigation into reducing postoperative opiate prescriptions.

This Month in Adult Urology

“…In a multi-institutional study by Fedrigon et al (page 373) patients were randomized and blinded post ureteroscopy to either oxycodone (5 mg) or ketorolac (10 mg) taken as needed with 3 nonblinded oxycodone rescue pills for breakthrough pain. 8 There was no difference between groups in postoperative pain scores, study medication, or rescue pain use. Patients receiving ketorolac had significantly fewer days confined to bed.…”

Effect of Cannabidiol Oil on Post-ureteroscopy Pain for Urinary Calculi: A Randomized, Double-blind, Placebo-controlled Trial

“…19 Recent studies have shown the effectiveness of anti-inflammatory medications on stent-related discomfort in the post-URS setting. 8 Theoretically, targeting the cannabinoid receptors within the urinary tract could decrease smooth muscle contractility, reduce inflammation, and subsequently decrease stent-related discomfort. It is within this framework that development of this study was prompted.…”

“…7 Furthermore, alternative analgesic agents, such as nonsteroidal anti-inflammatory medications, have proven noninferior to opioids in controlling pain after URS. 8 Despite these advances, the use of post-URS opioids remains high, and there is a continued focus to find new and alternative analgesic options for relieving patient stent discomfort. 9 Cannabidiol (CBD) oil represents a nonnarcotic analgesic agent which has shown promise in the treatment of chronic and cancer-related pain.…”

SKOPE—Study of Ketorolac vs Opioid for Pain after Endoscopy: A Double-Blinded Randomized Control Trial in Patients Undergoing Ureteroscopy. Letter.

“…To the Editor: We read with great interest the article by Matulay et al, which reported on contemporary outcomes of patients with nonmuscle-invasive bladder cancer treated with bacillus Calmette-Gu erin (BCG). 1 We think that the authors should be commended for completing this analysis, and we respectfully suggest that the most important message of this study is that final oncologic outcomes of patients with nonmuscle-invasive bladder cancer are totally dependent on the competency of the caring urologists. In essence, if basic requirements, including transurethral resection performed by expert surgeons, evaluation of resected specimens by dedicated genitourinary pathologists, second-look transurethral resections performed according to international guidelines, use of photodynamic-enhanced cystoscopy and resection, adequate BCG induction and maintenance courses, daily intensive collaboration with dedicated genitourinary medical oncologists, are respected, the results will be extremely good.…”

“…Francesco Montorsi, 1 Marco Moschini, 1 Andrea Necchi, 1 Federico Deho, 1 Giorgio Gandaglia We would like to thank Montorsi et al for their commentary emphasizing the implications of standardized, contemporary management of nonmuscle-invasive bladder cancer on bacillus Calmette-Gu erin (BCG) therapy outcomes. While they appropriately highlight that available resources at tertiary referral centers impact outcomes, we would like to posit and emphasize that guideline-concordant, evidence-based care does notdand should not!drequire exclusive expertise.…”