Outpatient Urological Procedures Research Articles

845 - Effect of music on outpatient urological procedures: A systematic review and meta-analysis from European section of Uro-Technology (ESUT)

Abstract Purpose Music is a practical, cheap and harmless analgesic and anxiolytic. An increasing number of original studies have been performed investigating its potential application in urology. Our aim was to identify the effect of music on outpatient based urological procedures. Method A systematic review was performed on the effect of using music during all reported outpatient urology procedures including transrectal ultrasound guided prostate biopsy (TRUS), shock-wave lithotripsy (SWL), urodynamic studies (UDS), percutaneous nephrostomy (PCN) tube placement and cystoscopy. Data was included for all randomised trials from 1980 to 2017 and no language restrictions were applied. Results Sixteen randomised studies were included (1950 patients) where 972 patients (49.8%) were exposed to music during their outpatient procedure. The procedures included TRUS biopsy (4 studies, n=286), SWL (6 studies, n=1023), Cystoscopy (3 studies, n=331), UDS (2 studies, n=210) and PCN (1 study, n=100). All studies incorporated visual analogue score (VAS) for pain measurement. The anxiety scores were measured by State-Trait anxiety Inventory (STAI) in 13 studies and VAS in 2 studies. While 14 of the 16 studies showed a reduction in self-reported pain, a reduction in anxiety was seen in 14 studies. Using music, the overall procedural satisfaction was better in 9 studies and the willingness to repeat the procedure was also higher in 7 studies. Our meta-analysis showed a significant reduction in both VAS and STAI across all studies (p Conclusion Our systematic review shows a beneficial effect of music on urology outpatient procedures. Music seems to decrease anxiety and pain and might serve as a useful adjunct to increase procedural satisfaction and willingness to undergo it again. Implications for clinical practice : Music seems to have a beneficial effect on the pain and anxiety on outpatient based procedures, which are carried out with patient awake or under a local anesthetic. The role of music should be acknowledged in future guideline recommendations as an adjunct for such procedures.

Effect of Music on Outpatient Urological Procedures: A Systematic Review and Meta-Analysis from the European Association of Urology Section of Uro-Technology

Music is a practical, inexpensive and harmless analgesic and anxiolytic. An increasing number of original studies have been performed to investigate its potential application in urology. Our aim was to identify the effect of music on outpatient based urological procedures. We systematically reviewed the effect of using music during all reported outpatient urology procedures, including transrectal ultrasound guided prostate biopsy, shock wave lithotripsy, urodynamic studies, percutaneous nephrostomy tube placement and cystoscopy. Data were included on all randomized trials from 1980 to 2017 and no language restrictions were applied. Included in analysis were 16 randomized studies in which 972 of 1,950 patients (49.8%) were exposed to music during an outpatient procedure. The procedures included transrectal ultrasound guided prostate biopsy in 4 studies in a total of 286 patients, shock wave lithotripsy in 6 studies in a total of 1,023, cystoscopy in 3 studies in a total of 331, urodynamics in 2 studies in a total of 210 and percutaneous nephrostomy in 1 study in a total of 100. All studies incorporated a visual analog score to measure pain. Anxiety was measured by STAI (State-Trait Anxiety Inventory) in 13 studies and by a visual analog scale in 2. While 14 of the 16 studies showed a reduction in self-reported pain, a reduction in anxiety was seen in 14. When using music, overall procedural satisfaction was better in 9 studies and patient willingness to repeat the procedure was also higher in 7. Our meta-analysis revealed a significant reduction in visual analog scale and STAI findings across all studies (p <0.001). Our systematic review demonstrated a beneficial effect of music on urological outpatient procedures. Music seemed to decrease anxiety and pain. It might serve as a useful adjunct to increase procedural satisfaction and patient willingness to undergo the procedure again.

Validation of antibiotic charges in administrative data for outpatient pediatric urologic procedures

The use of administrative health data for research has prompted questions about its validity for this purpose. The purpose of this study was to determine the concordance of Pediatric Health Information System (PHIS) perioperative antibiotic charges with the institution's medication administration data for males <10 years old and who underwent outpatient penile/inguinal procedures from July 2013 to March 2015. There was 93.9% positive and negative agreement between perioperative antibiotic charges versus administration. The sensitivity and specificity were 96.8% and 87.2%, respectively. The positive and negative predictive values were 94.6% and 92.2%, respectively. This study indicated strong agreement between PHIS pharmacy charges and medication administration.

Variation in Surgical Antibiotic Prophylaxis for Outpatient Pediatric Urological Procedures at United States Children’s Hospitals

Guidelines recommend surgical antibiotic prophylaxis for clean-contaminated procedures but none for clean procedures. The purpose of this study was to describe variations in surgical antibiotic prophylaxis for outpatient urological procedures at United States children's hospitals. Using the PHIS (Pediatric Health Information System®) database we performed a retrospective cohort study of patients younger than 18 years who underwent clean and/or clean-contaminated outpatient urological procedures from 2012 to 2014. We excluded those with concurrent nonurological procedures or an abscess/infected wound. We compared perioperative antibiotic charges for clean vs clean-contaminated procedures using a multilevel logistic regression model with a random effect for hospital. We also examined whether hospitals that were guideline compliant for clean procedures, defined as no surgical antibiotic prophylaxis, were also compliant for clean-contaminated procedures using the Pearson correlation coefficient. We examined hospital level variation in antibiotic rates using the coefficient of variation. A total of 131,256 patients with a median age of 34 months at 39 hospitals met study inclusion criteria. Patients undergoing clean procedures were 14% less likely to receive guideline compliant surgical antibiotic prophylaxis than patients undergoing clean-contaminated procedures (OR 0.86, 95% CI 0.84-0.88, p <0.0001). Hospitals that used antibiotics appropriately for clean-contaminated procedures were more likely to use antibiotics inappropriately for clean procedures (r = 0.7, p = 0.01). Greater variation was seen for hospital level compliance with surgical antibiotic prophylaxis for clean-contaminated procedures (range 9.8% to 97.8%, coefficient of variation 0.36) than for clean procedures (range 35.0% to 98.2%, coefficient of variation 0.20). Hospitals that used surgical antibiotic prophylaxis appropriately for clean-contaminated procedures were likely to use surgical antibiotic prophylaxis inappropriately for clean procedures. More variation was seen in hospital level guideline compliance for clean-contaminated procedures.

Taking the Procedure to the Patient: Increasing Access to Urological Procedural Care through Outreach

IntroductionWe previously showed that urological outreach clinics significantly increase access to urological clinical care in rural populations. How such clinics affect access to urological procedural care is unknown. In this study we analyzed the use of outreach facilities for outpatient hospital based urological procedural care in a rural state. MethodsUsing information from the Office of Statewide Clinical Education Programs and the Iowa Hospital Association database, we analyzed provider level data in Iowa from 2010 to 2013. Based on CPT codes all outpatient urological procedural care was categorized by procedure type and intent. Cities containing an Iowa Hospital Association hospital were characterized as primary vs outreach. Geographic data were used for analysis of travel metrics and proximity to urological procedural care sites. Outreach urological procedures were then compared to urological procedural care at primary centers. ResultsDuring the study period 11,464 outreach urological procedures were performed, accounting for 15.0% of all outpatient urological procedures in the state. The yearly number of outreach procedures remained relatively stable during the study period. The majority (51.7%) of outreach urological procedures were therapeutic and endoscopic (62.9%) in nature. Extracorporeal shock wave lithotripsy was significantly more common for treating stone disease in the outreach setting compared to ureteroscopy (p <0.0001). ConclusionsA large percentage of the total urological procedural care in our state was done at outreach clinics and, while the majority was of low acuity, it was therapeutic. Changes in health care are projected to affect rural hospitals, which rely heavily on procedural care, and this study is the first to our knowledge to demonstrate the role that urological procedural care can have in such locations.

MP32-20 TAKING THE PROCEDURE TO THE PATIENT: INCREASING ACCESS TO UROLOGIC PROCEDURAL CARE THROUGH OUTREACH

Abstract Introduction We previously showed that urological outreach clinics significantly increase access to urological clinical care in rural populations. How such clinics affect access to urological procedural care is unknown. In this study we analyzed the use of outreach facilities for outpatient hospital based urological procedural care in a rural state. Methods Using information from the Office of Statewide Clinical Education Programs and the Iowa Hospital Association database, we analyzed provider level data in Iowa from 2010 to 2013. Based on CPT codes all outpatient urological procedural care was categorized by procedure type and intent. Cities containing an Iowa Hospital Association hospital were characterized as primary vs outreach. Geographic data were used for analysis of travel metrics and proximity to urological procedural care sites. Outreach urological procedures were then compared to urological procedural care at primary centers. Results During the study period 11,464 outreach urological procedures were performed, accounting for 15.0% of all outpatient urological procedures in the state. The yearly number of outreach procedures remained relatively stable during the study period. The majority (51.7%) of outreach urological procedures were therapeutic and endoscopic (62.9%) in nature. Extracorporeal shock wave lithotripsy was significantly more common for treating stone disease in the outreach setting compared to ureteroscopy (p Conclusions A large percentage of the total urological procedural care in our state was done at outreach clinics and, while the majority was of low acuity, it was therapeutic. Changes in health care are projected to affect rural hospitals, which rely heavily on procedural care, and this study is the first to our knowledge to demonstrate the role that urological procedural care can have in such locations.

MP6-11 PREDICTORS OF READMISSION FOLLOWING OUTPATIENT UROLOGICAL SURGERY

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Practice Patterns, Cost Effectiveness I1 Apr 2014MP6-11 PREDICTORS OF READMISSION FOLLOWING OUTPATIENT UROLOGICAL SURGERY Aksharananda Rambachan, Richard S. Matulewicz, Matthew Pilecki, John YS. Kim, and Shilajit Kundu Aksharananda RambachanAksharananda Rambachan More articles by this author , Richard S. MatulewiczRichard S. Matulewicz More articles by this author , Matthew PileckiMatthew Pilecki More articles by this author , John YS. KimJohn YS. Kim More articles by this author , and Shilajit KunduShilajit Kundu More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2014.02.245AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The Patient Protection and Affordable Care Act increases oversight of surgical outcomes and ties readmissions to Medicare reimbursement. Given the increasing volume of outpatient urological procedures, we provide the first multi-institutional, multivariate analysis of the patient factors that contribute to readmission. METHODS Using the National Surgical Quality Improvement Program database from 2011, 7,795 patients were isolated. Multiple logistic regression was utilized to predict 30 day unplanned readmissions controlling for demographics, clinical characteristics and comorbidities. The readmission rates for the 5 most common procedures were calculated along with postoperative complications associated with readmission. RESULTS Outpatient urological surgery had an overall 3.7% readmission rate. The five most common procedures and their readmission rates were cystourethroscopy and resection of bladder tumor (4.97%), laser prostatectomy (4.27%), TURP (4.24%), excision of hydrocele (1.92%) and sling operation for urinary incontinence (0.85%). The most common comorbidities in the readmitted patients included hypertension, diabetes and smoking. Risk adjusted multiple regression indicated that cancer history (OR 3.48), bleeding disorder (OR 2.03), male gender (OR 1.38), ASA level 3 or 4 (OR 1.34) and age (OR 1.01) were significant predictors for readmission. Readmitted patients also had higher rates of 30-day complications. CONCLUSIONS Readmission after outpatient urological surgery occurs at a rate of 3.7%. A history of cancer, bleeding disorder, male gender, ASA level 3 or 4 and age were associated with readmission along with greater rates of medical and surgical complications. Our results may help guide risk reduction initiatives and prevent costly readmissions. Table 1. Predictors of readmission from regression analysis Factor OR p-value 95% C.I. Alcohol use 1.860 .056 .984 3.514 History of COPD 1.323 .197 .865 2.023 Previous percutaneous coronary intervention 1.218 .395 .773 1.917 Previous percutaneous coronary surgery 1.164 .538 .718 1.886 Hypertension .850 .236 .650 1.112 Disseminated Cancer∗ 3.484 .000 1.893 6.410 Steroid Use 1.700 .074 .951 3.042 Bleeding Disorder∗ 2.034 .006 1.227 3.373 Diabetes 1.328 .053 .996 1.771 Dyspnea 1.295 .201 .871 1.926 ASA Level 3 or 4∗ 1.335 .046 1.005 1.774 Function Status prior to Surgery 1.610 .128 .872 2.972 Male gender∗ 1.384 .038 1.018 1.882 Age (year)∗ 1.016 .001 1.006 1.026 ∗ p<.05 considered to be significant. Model: forced entry (one step), C-stat: .656 © 2014FiguresReferencesRelatedDetails Volume 191Issue 4SApril 2014Page: e60-e61 Advertisement Copyright & Permissions© 2014MetricsAuthor Information Aksharananda Rambachan More articles by this author Richard S. Matulewicz More articles by this author Matthew Pilecki More articles by this author John YS. Kim More articles by this author Shilajit Kundu More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Predictors of Readmission following Outpatient Urological Surgery

The Patient Protection and Affordable Care Act increases oversight of surgical outcomes and ties hospital readmissions to Medicare reimbursement. Given the increasing volume of outpatient urological procedures, to our knowledge this study provides the first multi-institutional multivariate analysis of patient factors that contribute to readmission. Using the 2011 National Surgical Quality Improvement Program database we identified 7,795 patients. Multiple logistic regression was used to predict 30-day unplanned hospital readmissions controlling for demographics, clinical characteristics and comorbidities. Readmission rates of the 5 most common procedures were calculated along with the rate of postoperative complications associated with readmission. Outpatient urological surgery had an overall 3.7% readmission rate. The 5 most common procedures were cystourethroscopy and resection of bladder tumor (readmission rate 4.97%), laser prostatectomy (4.27%), transurethral resection of prostate (4.24%), hydrocele excision (1.92%) and sling surgery for urinary incontinence (0.85%). The most common comorbidities in readmitted patients were hypertension, diabetes and smoking. Risk adjusted multiple regression indicated that cancer history (OR 3.48), bleeding disorder (OR 2.03), male gender (OR 1.38), ASA(®) level 3 or 4 (OR 1.34) and age (OR 1.01) were significant predictors of readmission. Readmitted patients also had a higher 30-day complication rate. Readmission after outpatient urological surgery occurs at a rate of 3.7%. A history of cancer, bleeding disorder, male gender, ASA level 3 or 4 and age were associated with readmission along with greater rates of medical and surgical complications. Our results may help guide risk reduction initiatives and prevent costly readmissions.

Medicare Payments for Outpatient Urological Surgery by Location of Care

The cost implications associated with offloading outpatient surgery from hospitals to ambulatory surgery centers and the physician office remain poorly defined. Therefore, we determined whether payments for outpatient surgery vary by location of care. Using national Medicare claims from 1998 to 2006, we identified elderly patients who underwent 1 of 22 common outpatient urological procedures. For each procedure we measured all relevant payments (in United States dollars) made during the 30-day claims window that encompassed the procedure date. We then categorized payment types (hospital, physician and outpatient facility). Finally, we used multivariable regression to compare price standardized payments across hospitals, ambulatory surgery centers and the physician office. Average total payments for outpatient surgery episodes varied widely from $200 for urethral dilation in the physician office to $5,688 for hospital based shock wave lithotripsy. For all but 2 procedure groups, ambulatory surgery centers and physician offices were associated with lower overall episode payments than hospitals. For instance, average total payments for urodynamic procedures performed at ambulatory surgery centers were less than a third of those done at hospitals (p <0.001). Compared to hospitals, office based prostate biopsies were nearly 75% less costly (p <0.001). Outpatient facility payments were the biggest driver of these differences. These data support policies that encourage the provision of outpatient surgery in less resource intensive settings.

Surgical Quality Among Medicare Beneficiaries Undergoing Outpatient Urological Surgery

The cost efficiency gains achieved from moving procedures to ambulatory surgery centers and offices may be mitigated if the quality of surgical care at these facilities is not comparable to that at the hospital. Motivated by this, we assessed short-term morbidity and mortality for patients by location of care. Using a national sample of Medicare claims (1998 to 2006), we identified elderly beneficiaries who underwent one of 22 common outpatient urological procedures. After determining the facility type where each procedure was performed, we measured 30-day mortality, unexpected admissions and postoperative complications. Finally, we fit multivariable logistic regression models to evaluate the association between occurrence of an adverse event and the ambulatory setting where surgical care was delivered. During the study period, there was a substantial increase in the frequency of nonhospital based outpatient surgery. Compared to ambulatory surgery centers and offices, hospitals treated more women (p <0.001). Those patients also tended to be less healthy (p <0.001). While patients experienced fewer postoperative complications following surgery at an ambulatory surgery center, procedures performed outside the hospital were associated with a higher likelihood of a same day admission (ambulatory surgery centers OR 6.96, 95% CI 4.44-10.90 and offices OR 3.64, 95% CI 2.48-5.36). However, notably with case mix adjustment the probability of any adverse event was exceedingly low across all ambulatory settings. These data indicate that small but measurable variation in surgical quality exists by location of care delivery.

Outpatient urological procedures in antibiotic-naive patients with bladder cancer with asymptomatic bacteriuria

Study Type - Therapy (case series) Level of Evidence 4 What's known on the subject? and What does the study add? Urine culture and antibiotics are usually given before outpatient urological procedures, namely cystoscopy or intravesical BCG therapy. Injudicious use of antibiotics promotes multidrug bacterial resistance. Pretreatment antibacterial therapy may not be necessary before outpatient urological procedures in patients with bladder cancer. Such strategy facilitates timely intervention and avoids antibiotic resistance. • To investigate the frequency of infectious complications after intravesical BCG therapy or cystoscopy in antibiotic-naive patients with bladder tumours who have asymptomatic bacteriuria. • The aim was to avoid antibiotics in infected patients undergoing these common outpatient urological procedures. • A total of 354 patients received induction BCG therapy and another 663 patients underwent cystoscopy after submitting a voided urine sample for culture. They received no antibiotics before or after the procedure. • Significant bacteriuria was defined as >10(4) or >10(5) colony-forming units per millilitre with a single organism. • The patients were followed for 3 months for onset of febrile UTI, defined as dysuria and fever >38 °C requiring antibiotics. • Ninety BCG-treated patients (25%) and 114 cystoscopy patients (17%) had bacteriuria. • After BCG therapy, two patients with infected urine (2.2%) and three with sterile cultures (1.1%) had febrile UTIs (P= 0.17). • After cystoscopy, four infected patients (3.5%) and five uninfected patients (1%) had febrile UTIs (P= 0.08). • All UTIs resolved within 24 h with oral antibiotics, and none of the patients was admitted for bacterial sepsis. • Antibacterial prophylaxis before intravesical BCG therapy or outpatient cystoscopy does not appear to be necessary in patients with asymptomatic bacteriuria. • Such strategy avoids overuse of antibiotics, reducing drug-resistant bacterial infections.

Comment on: Entonox&lt;SUP&gt;®&lt;/SUP&gt; inhalation to reduce pain in common diagnostic and therapeutic outpatient urological procedures: a review of the evidence KD Johnston

Comment on: Entonox&lt;SUP&gt;®&lt;/SUP&gt; inhalation to reduce pain in common diagnostic and therapeutic outpatient urological procedures: a review of the evidence KD Johnston

Entonox® inhalation to reduce pain in common diagnostic and therapeutic outpatient urological procedures: a review of the evidence

Entonox(®) (50% nitrous oxide and 50% oxygen; BOC Healthcare, Manchester, UK) is an analgesic and anxiolytic agent that is used to successfully reduce pain and anxiety during dental, paediatric and emergency department procedures. In this article we review the application and efficacy of Entonox(®) in painful local anaesthesia urological procedures by performing a systematic review of the literature. A MEDLINE(®) search was performed using the terms 'nitrous oxide', 'Entonox', 'prostate biopsy', 'flexible cystoscopy' and 'extracorporeal shock wave lithotripsy'. English language publications of randomised studies were identified and reviewed. The search yielded five randomised studies that investigated the clinical efficacy of Entonox(®) as an analgesic for day case urological procedures. Three randomised controlled trials (RCTs) investigated Entonox(®) in transrectal ultrasonography guided prostate biopsy. All three reported significant reductions in pain score in the Entonox(®) versus control groups. One RCT reported significant reduction in pain during male flexible cystoscopy in the Entonox(®) group compared with the control group. One RCT, which examined the use of Entonox(®) during extracorporeal shock wave lithotripsy, found its use significantly decreased the pain score compared with the control group and this was comparable to intravenous pethidine. Evidence from varied adult and paediatric procedures has shown Entonox(®) to be an effective, safe and patient acceptable form of analgesia. All published studies of its use in urological day case procedures have found it to significantly reduce procedural pain. There is huge potential to use this cheap, safe, effective analgesic in our current practice.

40 DO SHORT-TERM OUTCOMES FOLLOWING COMMON UROLOGIC PROCEDURES VARY BY THE AMBULATORY CARE SETTING WHERE THEY WERE PERFORMED?

You have accessJournal of UrologyGeneral & Epidemiological Trends & Socioeconomics: Evidence-based Medicine & Outcomes1 Apr 201140 DO SHORT-TERM OUTCOMES FOLLOWING COMMON UROLOGIC PROCEDURES VARY BY THE AMBULATORY CARE SETTING WHERE THEY WERE PERFORMED? John M. Hollingsworth, Julie C. Lai, Christopher S. Saigal, Christopher P. Filson, Brent K. Hollenbeck, and Urologic Diseases in America Project, Los Angeles, CA John M. HollingsworthJohn M. Hollingsworth Ann Arbor, MI More articles by this author , Julie C. LaiJulie C. Lai Santa Monica, CA More articles by this author , Christopher S. SaigalChristopher S. Saigal Los Angeles, CA More articles by this author , Christopher P. FilsonChristopher P. Filson Ann Arbor, MI More articles by this author , Brent K. HollenbeckBrent K. Hollenbeck Ann Arbor, MI More articles by this author , and Urologic Diseases in America Project, Los Angeles, CA More articles by this author View All Author Informationhttps://doi.org/10.1016/j.juro.2011.02.103AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookTwitterLinked InEmail INTRODUCTION AND OBJECTIVES The savings achieved by payers from steering urologic procedures to ambulatory surgery centers (ASCs) and physician offices (POs) may be wholly mitigated if the quality of care at these less resource-intense facilities is not comparable to that of hospital outpatient departments (HOPDs). Motivated by this concern, we assessed short-term outcomes for patients across ambulatory care settings. METHODS Using a 5% random sample of Medicare beneficiaries (1998–2006), we identified elderly adults who underwent one of 20 common outpatient urologic procedures. Through appropriate place-of-service and revenue codes, we determined the facility type at which each procedure was performed (i.e., HOPD, ASC, or PO). We then measured the incidence of same-day admissions, as well as the frequency of hospitalization, complications, and death within 30 days of the index date. Finally, we fit multivariable logistic regression models to evaluate the association between an event occurrence and the ambulatory setting where care was delivered. RESULTS Over the study period, the proportion of procedures performed at ASCs remained relatively stable. However, there was a substantial increase in frequency PO-based procedures, reflecting a shift in care away from HOPDs. While patients treated in a PO (versus a HOPD) had lower odds of experiencing an adverse event (OR, 0.90; 95% CI, 0.81–0.99), the predicted probability of any adverse event was exceedingly low irrespective of the ambulatory care setting (Figure). CONCLUSIONS These data indicate a shift in outpatient urologic care to the PO. Insofar as the care provided in these facilities is less expensive, this trend represents delivery of higher value care for payers. © 2011 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 185Issue 4SApril 2011Page: e16-e17 Advertisement Copyright & Permissions© 2011 by American Urological Association Education and Research, Inc.MetricsAuthor Information John M. Hollingsworth Ann Arbor, MI More articles by this author Julie C. Lai Santa Monica, CA More articles by this author Christopher S. Saigal Los Angeles, CA More articles by this author Christopher P. Filson Ann Arbor, MI More articles by this author Brent K. Hollenbeck Ann Arbor, MI More articles by this author Urologic Diseases in America Project, Los Angeles, CA More articles by this author Expand All Advertisement Advertisement PDF downloadLoading ...

Meatotomy Using Local Anesthesia and Sedation or General Anesthesia With or Without Penile Block in Children: A Prospective Randomized Study

Meatotomy is a simple, common procedure for the treatment of meatal stenosis. We compared the outcomes of meatotomy performed using local anesthesia and sedation, and general anesthesia with and without penile block. A prospective comparative design was used. Participants included 76 boys 1.5 to 10 years old treated for meatal stenosis at a tertiary, university affiliated, pediatric medical center in 2008. Children were randomly allocated to undergo surgery with sedation and local anesthesia, or general anesthesia with or without penile block. All procedures were performed with the same method by the same surgeon. For local anesthesia EMLA 5% cream (lidocaine 2.5% and prilocaine 2.5%) covered with an occlusive dressing was applied 1 hour preoperatively, and midazolam (in patients younger than 5 years) or nitrous oxide (older than 5 years) was used for sedation. General anesthesia was induced with inhaled sevoflurane, and ropivacaine was used for dorsal penile nerve block. There was no difference among the groups in pain level intraoperatively (no pain in 92% to 93% of patients), 24 hours postoperatively (no pain in 81% to 88%) or after 1 month, or in complication rates (bleeding in 3 patients, laryngospasm in 2). General anesthesia with penile block was associated with a trend of less dysuria. Quality of void was excellent in 87% of patients at 24 hours and in 70% at 1 month, and parental satisfaction was high (88% to 92%). Meatotomy performed using local anesthesia and sedation has an equally good outcome to meatotomy performed using general anesthesia with or without penile block.

Comparison of remifentanil versus fentanyl general anesthesia for short outpatient urologic procedures

Study objectives. To compare the effect of remifentanil versus fentanyl isoflurane general anesthesia on Aldrete score, emergence, extubation and discharge times from the operating room (OR) and postanesthesia care unit (PACU) following short outpatient urologic procedures (panendoscopy and cystoscopy, bladder hydrodilatation, stent placement). Patients and methods. 40 patients 18 years of age or older scheduled for short elective outpatient urological procedures with an expected duration of less than 30 minutes.Following Institutional Review Board (IRB) approval and written informed consent, 40 American Society of Anesthesiologi-sts (ASA) physical class 1-3 adult outpatients were enrolled and equally (n=20) randomized into remifentanil and fentanyl groups. Preoperatively, all subjects received intravenous (IV) midazolam 1-2 mg and were induced with propofol 2 mg/kg IV. Muscle relaxation was achieved with succinylcholine or rocuronium, followed by intubation. The remifentanil group received remifentanil 1 g/kg IV at induction with a maintenance dose of remifentanil 0.1 to 2 g/kg/min IV in the presence&nbsp;of 60% nitrous oxide (N2O)/40% oxygen (O2) and end-tidal isoflurane of 0.3 to 0.4% (for amnesia). The fentanyl group received fentanyl 2 g/kg IV at induction, maintenance dose of fentanyl 2 to 3 g/kg IV intermittent bolus, and 60% N2O/40%O2 with 2% end-tidal isoflurane. Muscle relaxation was reversed at the end of anesthesia as needed. Times for OR entry, emergence, extubation, total OR time (entry to exit) and PACU discharge time, as well as Aldrete scores at time of OR exit and PACU discharge were determined. Data was evaluated by ANOVA, t-test and Mann-Whitney tests. A p&lt;0.05 value was considered statistically significant.Results. There was no significant difference between groups in age, gender, weight, ASA class, PACU analgesic or antie-metic use, or times of emergence, extubation, OR exit and PACU discharge. There was a significant difference (p&lt;0.05) in OR exit Aldrete score but not PACU discharge Aldrete score. No adverse events were noted.Conclusions. While there was no difference between the remifentanil and fentanyl groups regarding recovery time from OR and PACU, remifentanil patients had significantly better OR exit Aldrete scores with less sedation upon arrival at phase I PACU recovery than the fentanyl group. This anesthesia technique may prove helpful for fast-track eligibility of these patients.&nbsp;&nbsp

Prophylactic Use of Antimicrobials in Commonly Performed Outpatient Urologic Procedures

Prophylactic Use of Antimicrobials in Commonly Performed Outpatient Urologic Procedures

Prophylactic use of antimicrobials in commonly performed outpatient urologic procedures

An antimicrobial is an agent capable of killing or inhibiting the growth of a micro-organism. Antimicrobial prophylaxis encompasses efforts to prevent postprocedure infections through the use of an antimicrobial agent before, and, in some cases, for a limited time after a procedure. A thorough history and physical examination are essential to identify host factors that increase a patient's risk for postprocedural infection. Risk-modifying factors include age, anatomy, geographical area of residence, immune and nutritional status, cardiac valve integrity, prosthetic joints, the presence of indwelling hardware and distant infectious wounds. Prophylaxis for the most common urologic outpatient procedures can be attained with oral trimethoprim-sulfamethoxazole or fluoroquinolone administered between 2 h and 30 min before a procedure. Special consideration for the type and duration of prophylaxis should be given to patients with moderate to severe cardiac valvular conditions and recently inserted prosthetic joints.

The changing role of monitored anesthesia care in the ambulatory setting.

The changing role of monitored anesthesia care in the ambulatory setting.

Postoperative pain following outpatient pediatric urologic surgery: A comparison of anesthetic techniques

Objectives. To evaluate and compare the efficacy of caudal and local nerve blocks in preventing pain following outpatient pediatric urologic surgery. Methods. Seventy-seven boys undergoing outpatient urologic surgery were randomized into one of three groups: general anesthesia alone, general anesthesia and caudal nerve block, or general anesthesia and local nerve block. Pain scores, frequency of medication, and total dosage of medication were recorded in the immediate postoperative period. Long-term pain and discomfort were measured using â 24-hour and 1-week questionnaire. Results. The caudal and local groups had lower pain scores and significantly lower medication requirements than the control group in the short-term postoperative period. The caudal group had lower pain scores than the local group in all categories; however, the only significant difference was at 24 hours postoperatively. At 1 week postoperatively, the only difference among the three groups was a lower pain score in the caudal group compared with the control group. Conclusions. This study demonstrates that for outpatient pediatric urologic procedures,both caudal and local nerve blocks significantly reduce pain and medication given in the immediate postoperative period and indicates that caudal block may decrease pain for up to 1 week following surgery.