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Michael Conlin’s commentary on NSAIDs

Pain relief after ureteric stent removal: think NSAIDs

Nicholas N. Tadros, Lisa Bland, Edith Legg, Ali Olyaei and Michael J. Conlin*
Oregon Health & Science University and *Portland Veterans Administration Medical Center, Portland, OR, USA

OBJECTIVES

• To determine the incidence of severe pain after ureteric stent removal.

• To evaluate the efficacy of a single dose of a non-steroidal anti-inflammatory drug (NSAID) in preventing this complication.

PATIENTS AND METHODS

• A prospective, randomised, double-blind, placebo-controlled trial was performed at our institution.

• Adults with an indwelling ureteric stent after ureteroscopy were randomised to receive either a single dose of placebo or an NSAID (rofecoxib 50 mg) before ureteric stent removal.

• Pain was measured using a visual analogue scale (VAS) just before and 24 h after stent removal

• Pain medication use after ureteric stent removal was measured using morphine equivalents.

RESULTS

• In all, 22 patients were enrolled and randomised into the study before ending the study after interim analysis showed significant decrease in pain level in the NSAID group.

• The most common indication for ureteroscopy was urolithiasis (14 patients).

• The proportion of patients with severe pain (VAS score of ≥7) during the 24 h after ureteric stent removal was six of 11 (55%) in the placebo group and it was zero of 10 in the NSAID group (P < 0.01).

• There were no complications related to the use of rofecoxib.

CONCLUSIONS

• We found a 55% incidence of severe pain after ureteric stent removal.

• A single dose of a NSAID before stent removal prevents severe pain after ureteric stent removal.

Tadros NN, Bland L, Legg E, et al. A single dose of a non-steroidal anti-inflammatory drug (NSAID) prevents severe pain after ureteric stent removal: a prospective, randomised, double-blind, placebo-controlled trial. BJU Int 2013, 111: 101–105.

John Eifler and Alan Partin discuss their article

An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011.

John B. Eifler, Zhaoyang Feng, Brian M. Lin, Michael T. Partin, Elizabeth B. Humphreys, Misop Han, Jonathan I. Epstein, Patrick C. Walsh, Bruce J. Trock and Alan W. Partin
James Buchanan Brady Urological Institute and the Department of Urology, Johns Hopkins Medical Institutions, Baltimore, MD, USA

Objective

  • To update the 2007 Partin tables in a contemporary patient population.

Patients and Methods

The study population consisted of 5,629 consecutive men who underwent RP and staging lymphadenectomy at the Johns Hopkins Hospital between January 1, 2006 and July 30, 2011 and met inclusion criteria.

  • Polychotomous logistic regression analysis was used to predict the probability of each pathologic stage category: organ-confined disease (OC), extraprostatic extension (EPE), seminal vesicle involvement (SV+), or lymph node involvement (LN+) based on preoperative criteria.
  • Preoperative variables included biopsy Gleason score (6, 3+4, 4+3, 8, and 9–10), serum PSA (0–2.5, 2.6–4.0, 4.1–6.0, 6.1–10.0, greater than 10.0 ng/mL), and clinical stage (T1c, T2c, and T2b/T2c).
  • Bootstrap re-sampling with 1000 replications was performed to estimate 95% confidence intervals for predicted probabilities of each pathologic state.

Results

  • The median PSA was 4.9 ng/mL, 63% had Gleason 6 disease, and 78% of men had T1c disease.
  • 73% of patients had OC disease, 23% had EPE, 3% had SV+ but not LN+, and 1% had LN+ disease. Compared to the previous Partin nomogram, there was no change in the distribution of pathologic state.
  • The risk of LN+ disease was significantly higher for tumors with biopsy Gleason 9–10 than Gleason 8 (O.R. 3.2, 95% CI 1.3–7.6).
  • The c-indexes for EPE vs. OC, SV+ vs. OC, and LN+ vs. OC were 0.702, 0.853, and 0.917, respectively.
  • Men with biopsy Gleason 4+3 and Gleason 8 had similar predicted probabilities for all pathologic stages.
  • Most men presenting with Gleason 6 disease or Gleason 3+4 disease have <2% risk of harboring LN+ disease and may have lymphadenectomy omitted at RP.

Conclusions

  • The distribution of pathologic stages did not change at our institution between 2000–2005 and 2006–2011.
  • The updated Partin nomogram takes into account the updated Gleason scoring system and may be more accurate for contemporary patients diagnosed with prostate cancer.

Eifler JB, Feng Z, Lin BM, et al. An updated prostate cancer staging nomogram (Partin tables) based on cases from 2006 to 2011. BJU Int 2013; 111: 26–33.

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