Pain most common reason for post-URS ED visits

Pain is the most common reason for emergency department (ED) visits in the 30 days following ureteroscopy, according to a 6-month review of cases conducted at Scott and White Medical Center, Temple, TX.

Among 47 ED visits within 30 days of elective ureteroscopy over the 6-month span, pain was the presenting complaint in about 60% of patients, reported Luke Machen, MD, at the AUA annual meeting. The type of pain medication prescribed at discharge did not affect the likelihood of an ED visit for pain.

Better counseling about the discomfort to be expected with stents and the management of expectations may reduce the rate of ED visits for pain, although this hypothesis remains to be proved, said Dr. Machen, who worked on the study with Marawan El Tayeb, MD, and colleagues.  

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“I think some of it is it just hurts a little more than they expect, and if we were better about counseling and the patients know what’s coming, we may see a decrease in ED visits,” he said.

A retrospective chart review was conducted from July 1, 2015 to Dec. 31, 2015 to identify patients who returned to the ED within 30 days of elective ureteroscopy. The 30-day endpoint was chosen because hospital reimbursement for readmissions within 30 days is reduced as part of quality improvement measures instituted under the Affordable Care Act and the Centers for Medicare & Medicaid Services.

A total of 330 ureteroscopies were performed over the 6 months. Twenty-seven patients (57.4%) were pre-stented at an average of 11.5 days preoperatively. All patients were discharged with a stent in place, 26 (55.3%) of whom had a string attached with instructions for removal at home. Forty patients (85.1%) were discharged with either codeine/acetaminophen (Tylenol #3) or tramadol (Ultram) for pain control.

Next: Rate of return consistent with reports in the literature

There were 47 ED visits (29 by women and 18 by men, average age: 48.2 years) that occurred at an average of 8.4 days following ureteroscopy, for a rate of return of 14.2%. This rate is consistent with reports in the literature, Dr. Machen noted. For example, Bloom et al found a rate of ED return of 15.6% within 30 days in a series of 276 patients undergoing ureteroscopy (J Urol 2016; 195:1487-91). Buldu and colleagues found that 12.7% of patients were re-admitted within 30 days after flexible ureterorenoscopy for kidney stones (World J Urol 2016; 34:1291-5).

As in these other two series, the most common presenting complaint was flank pain (28 patients; 59.6%).

“There was no statistically significant difference in the trips to the ED based on pain medication,” said Dr. Machen.

“In the 28 patients who presented with pain, a large percentage of them presented on the same day that their stent had been removed, whether they had pulled it themselves or had it removed as an outpatient procedure in clinic, or else that it had been removed on accident,” he said.

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These percentages were 46.4% after the stent was self-pulled, 10.7% after the stent was inadvertently removed, and 14.3% after the stent was removed via cystoscopy in clinic. About one-fourth (28.6%) who presented with flank pain presented with the stent in place. There was no significant difference in the rate of ED visits between those who had a string attached and those who did not.

The second most common reason for ED visit was hematuria (five patients). Nine of the 47 patients underwent intraoperative dilation of their ureters and in 29 of the 47, an access sheath was used. Fifteen of the 47 patients presenting to the ED were ultimately hospitalized.

A multivariable analysis will assess comorbidities and their effect on returning to the ED, Dr. Machen said.