Abstracts from the New England Section of the AUA 2020: A Virtual Experience

© The Canadian Journal of Urology TM : International Supplement, August 2020 24 hour Observation through Novel Stone Observation Pathway within Emergency Department Predicts Success of Outpatient Medical Expulsive Therapy Meredith C. Wasserman, MD, MS , Siddharth Marthi, BS, David W. Sobel, MD, Edmond Godbout, PA, Chris Tucci, MS RN, Gyan Pareek, MD, MS Brown University, Providence, RI Introduction: The incidence of nephrolithiasis continues to increase and safe emergency department management of acute renal colic is critical to patient outcomes. With the understanding that the majority of ureteral stones will pass spontaneously with outpatient medicalexpulsivetherapy(MET),achievingpaincontrolandtreatingassociatedsymptoms to allow for safe discharge is paramount. In 2016 we developed a novel stone observation pathway (SOP) within our institution’s Clinical Decision Unit (CDU) for patients with acute renal colic to have up to 24 hours of observation with the goal of a safe discharge on MET without requiring hospital admission or urologic consultation. The purpose of this study is to evaluate the safety and efficacy of the 24 hour observation model through a SOP for patients with acute renal colic. Materials & Methods: A retrospective review of all patients admitted to the CDU utilizing the SOP from January 2016 to November 2019 was performed. Patients with ureterolithiasis were excluded from admission to the CDU if any single criteria from Table 1 was met. Patient characteristics, axial imaging, and follow up information were analyzed. Of note, it was assumed if a patient did not follow up with a urologist, they did not undergo surgical intervention for their ureteral stone. MET was considered successful if the patient did not return to the emergency department. Urologic consultation was not required during observation, however the urologist on call was alerted to patients with acute kidney injury, severe hydronephrosis, or calculi > 10 mm. Results: 189 patients were diagnosed with uncomplicated ureterolithiasis and admitted via the SOP to the CDU (Table 2). The mean stone size was 4.6mm (SD +/- 1.9 mm). 148/189 (78%) patients were discharged within the 24 hour observation period and 42 patients were admitted for operative intervention (22%). 17 patients discharged from the unit returned to the emergency department for recurrent renal colic (9%) and 8 of these required admission for operative intervention (53%). 85 patients discharged from the unit followed up with a urologist (57%) and 30 of these patients ultimately required surgical intervention (22%). There were no readmissions for infection or sepsis. Conclusions: 24hourobservationanddischargefromaCDU intheemergencydepartment using a SOP predicts success of outpatient MET. The protocol is both effective (< 10% readmission rate) and safe (0% readmission for UTI/pyelonephritis). Additionally, by avoiding admission to a urology service for observation, the urologist can focus efforts on more acute surgical consultation and management. Partnership between the divisions of urology and emergency medicine is critical for the success of the SOP. Future research will evaluate the cost savings of this protocol as well as low follow-up rate (57.4%) as an area for quality improvement. Patterns of Opioid Prescription Post Ureteroscopy Among Members of the Endouro- logical Society Mohannad A. Awad, MD 1 , DavidW. Sobel, MD 2 , Ben H. Chew, MD 3 , Benjamin N. Breyer, MD 4 , Mark K. Plante, MD 1 , Kevan M. Sternberg, MD 1 1 University of Vermont Medical Center, Burlington, VT; 2 The Minimally Invasive Urology In- stitute at the Mariam Hospital, Warren Alpert Medical School of Brown University, Providence, RI; 3 University of British Columbia, Vancouver, BC, Canada; 4 University of California - San Francisco, San Francisco, CA Introduction: Post-operative opioid prescription has been linked with persistent opioid use. Ureteroscopy (URS) is one of the most common urologic procedures, and therefore a potential area of focus to limit opioid prescribing among urologists. The aims of this study are to characterize national and international practice patterns of opioid prescription post URS and define reasons for opioid use in this setting. Materials &Methods: We developed a survey directed tomembers of the Endourological Society. The surveywas composed of 12-16 questions targeting practice patterns, frequency of opioid prescription post ureteroscopy, challenges facedwhen opioids are not prescribed and specific measures thought to be helpful to reduce the need for opioid prescriptions. The final survey was electronically distributed to 2000 Endourological Society members listed in the 2018-2019 Membership Directory. Accrual period was during May 2019. Results: With a response rate of 8% (159/2000), the majority of respondents reported practicing urology for > 20 years (37.1%), and performing 10-20 ureteroscopies/month (45.3%). Around 40% of respondents were from the United States (US) and Canada. 66% completed a fellowship, 84% of which were endourology. 26% report routinely prescribing opioids and the majority do so less than 10% of the time (62.3%). 38% had no challenges when opioids were omitted. Measures felt to decrease the need for opioids were preopera- tive counseling, nonsteroidal anti-inflammatory drugs use, and use of adjunct medications. After adjusting for location, practice type, endourology fellowship completion, years of practice, and number of ureteroscopies/month, we found that respondents from the US and Canada were more likely to prescribe opioids routinely post URS, (Odds Ratio 87.5, P < 0.001, 95% Confidence Interval 17.3-443.5). Conclusions: Among participants in our survey, nearly one quarter of urologists prescribe opioids routinely post URS, and US and Canadian urologists were more likely to prescribe routinely compared to the rest of the world. Despite proven feasibility of non-opioidman- agement following URS, many urologists continue to prescribe opioids in this setting. We believe best practice guidelines by the American and Canadian Urological Associations should be considered to reduce opioid prescribing post ureteroscopy. 17 16 8 Scientific Session II: Stones I