Dr. Michael J. Conlin told Reuters Health by email “Ureteral stenting after ureteroscopy causes the most significant morbidity for most patients, and may limit the utilization of ureteroscopy. An overlooked stent related morbidity is the renal colic like pain that may occur after ureteral stent removal.”
Dr. Conlin of Portland Veterans Administration Medical Center and colleagues note that work has been done on reducing pain associated with indwelling stents, but, there are no reports on analgesia for stent removal. A promising approach is use of NSAIDs which can decrease renal colic by reducing ureteric contractility and inflammation via inhibition of cyclooxygenase (COX).
To investigate, the team randomized 22 patients to receive a single dose of rofecoxib 50 mg or placebo before ureteric stent removal. One patient was lost to follow-up. A visual analogue scale was used to assess pain just before and 24 hours after stent removal. Most patients (14) had stent removal after successful ureteroscopic treatment for urolithiasis.
Six of the eleven patients in the placebo group experienced severe pain in the 24 hours after stent removal compared to none in the active treatment group. Moreover, two patients in the placebo group required evaluation and treatment in an emergency department for continued pain, one required admission.
Because of the marked decrease in severe pain in the NSAID group, the study was terminated. Subsequently, rofecoxib, the NSAID of choice due to its selective COX-2 inhibition and decreased gastrointestinal adverse effects, was withdrawn.
The investigators currently use naproxen 220 mg (a nonselective COX inhibitor) as the NSAID of choice. “Naproxen,” continued Dr. Conlin “is a non-steroidal anti-inflammatory just like rofecoxib, so I consider this the same. And naproxen is cheap and works well. This is definitely the standard in my practice.”
The approach he added, “is now our routine when removing ureteral stents. There may be other strategies to reduce this problem, such as the use of alpha blocker medication prior to ureteral stent removal, and we hope to study this in the near future.”