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The Journal of Urology Feb 2017There is currently a national shortage of indigo carmine. In efforts to identify the most efficient aid for visualizing ureteral efflux intraoperatively we investigated... (Comparative Study)
Comparative Study
PURPOSE
There is currently a national shortage of indigo carmine. In efforts to identify the most efficient aid for visualizing ureteral efflux intraoperatively we investigated the time to excretion of phenazopyridine vs a newly identified alternative, sodium fluorescein.
MATERIALS AND METHODS
We analyzed prospectively collected data on a cohort of women who underwent pelvic reconstructive surgery in 2015. Per provider preference patterns a number of patients were administered 200 mg phenazopyridine orally with a sip of water 1 hour prior to the start of operative time. Other patients were given 0.5 ml 10% sodium fluorescein intravenously in the operating room. In all cases time was measured between the administration of the agent and the visualization of color changes consistent with agent efflux in an indwelling catheter, which was placed at the start of the operation. Differences in excretion times between the groups were compared with the Wilcoxon rank sum test.
RESULTS
Seven women received phenazopyridine and 5 received sodium fluorescein. Mean excretion time was significantly longer in the phenazopyridine group compared to the sodium fluorescein group (81.9 vs 5.1 minutes, p = 0.0057). Median excretion time for phenazopyridine was 70 minutes (range 59 to 127) and for sodium fluorescein it was 5 minutes (range 3 to 9).
CONCLUSIONS
Sodium fluorescein is excreted significantly faster in the operating room compared to phenazopyridine. Depending on the cost of these agents at an institution, in addition to the desire to decrease operative time, this may impact practice patterns and agent selection.
Topics: Adult; Aged; Aged, 80 and over; Cystoscopy; Female; Fluorescein; Fluorescent Dyes; Humans; Iatrogenic Disease; Intraoperative Complications; Middle Aged; Pelvic Floor; Phenazopyridine; Plastic Surgery Procedures; Ureter; Urinary Catheters
PubMed: 27664579
DOI: 10.1016/j.juro.2016.07.099 -
American Journal of Obstetrics and... Jan 2022Intraoperative evaluation of ureteral patency is often performed in gynecologic and urogynecologic surgery. Many agents are used to help assess the patency, each with...
BACKGROUND
Intraoperative evaluation of ureteral patency is often performed in gynecologic and urogynecologic surgery. Many agents are used to help assess the patency, each with its own associated cost, ease of use, and adverse reactions. Some agents, such as dextrose, are used as an instillation fluid to create a viscosity difference and aid the visualization of a ureteral jet. Others, such as oral phenazopyridine or the intravenous use of sodium fluorescein and indigo carmine, cause a color change of the urine to directly aid the visualization of ureteral jets. Recently, numerous studies have examined the efficacy and surgeon satisfaction of these agents. The studies have also emphasized certain options as associated with a lower cost. However, there have not been any cost studies comparing these agents.
OBJECTIVE
To compare the cost-effectiveness of the following 4 agents that are commonly used in assessing ureteral patency intraoperatively: oral phenazopyridine, dextrose instillation, intravenous sodium fluorescein, and intravenous indigo carmine.
STUDY DESIGN
We constructed a decision-analytic model to compare cystoscopy using oral phenazopyridine, dextrose instillation, intravenous sodium fluorescein, and intravenous indigo carmine. Failure to see efflux resulted in work-ups for ureteral obstruction. The probabilities were obtained from published studies, and the probability of successfully seeing efflux ranged from 0.92 with oral phenazopyridine to 0.99 with intravenous indigo carmine. The costs of the agents, adverse effects, and ureteral obstruction work-ups were obtained from the University of North Carolina at Chapel Hill Department of Pharmacy, the Healthcare Cost and Utilization Project 2016 database and the FAIR Health Consumer database. The cost of a ureteral obstruction work-up used in our model ranged from $9755 for intraoperative evaluation with retrograde pyelograms and stents to $29,034 for hospitalization. Our primary outcome was the incremental cost-effectiveness ratio per unnecessary work-up for ureteral obstruction avoided. Sensitivity analyses were performed to identify the key uncertainties.
RESULTS
Oral phenazopyridine, followed by an intravenous agent if needed, had a mean cost of $110 per patient. Dextrose averaged $151 more per patient, with only a slight improvement in avoiding unnecessary ureteral obstruction work-ups and a higher cost associated with adverse reactions (incremental cost-effectiveness ratio, $62,000). Intravenous agents cost approximately $1000 more per patient and were less effective at preventing unnecessary work-ups. Sensitivity analyses did not identify any thresholds that would significantly change the outcomes.
CONCLUSION
Our model suggests that oral phenazopyridine and dextrose instillation are the least expensive and the most effective agents to aid in the visualization of ureteral patency during intraoperative cystoscopy, although dextrose is associated with higher costs owing to a higher rate of adverse reactions (primarily urinary tract infections). Intravenous sodium fluorescein and indigo carmine are historically popular first-choice agents. However, they were found to be more expensive and less effective as primary agents in our model and should likely be reserved for use as secondary agents in the event that the visualization of ureteral jets is unclear with the initial use of phenazopyridine or dextrose.
Topics: Coloring Agents; Cost-Benefit Analysis; Cystoscopy; Female; Fluorescein; Gynecologic Surgical Procedures; Humans; Indigo Carmine; Intraoperative Complications; North Carolina; Phenazopyridine; Ureteral Obstruction
PubMed: 34487702
DOI: 10.1016/j.ajog.2021.08.055 -
Journal of Virology Jun 2019Coronaviruses (CoVs) act as cross-species viruses and have the potential to spread rapidly into new host species and cause epidemic diseases. Despite the severe public...
Coronaviruses (CoVs) act as cross-species viruses and have the potential to spread rapidly into new host species and cause epidemic diseases. Despite the severe public health threat of severe acute respiratory syndrome coronavirus and Middle East respiratory syndrome CoV (MERS-CoV), there are currently no drugs available for their treatment; therefore, broad-spectrum inhibitors of emerging and endemic CoVs are urgently needed. To search for effective inhibitory agents, we performed high-throughput screening (HTS) of a 2,000-compound library of approved drugs and pharmacologically active compounds using the established genetically engineered human CoV OC43 (HCoV-OC43) strain expressing luciferase (rOC43-ns2Del-Rluc) and validated the inhibitors using multiple genetically distinct CoVs We screened 56 hits from the HTS data and validated 36 compounds using wild-type HCoV-OC43. Furthermore, we identified seven compounds (lycorine, emetine, monensin sodium, mycophenolate mofetil, mycophenolic acid, phenazopyridine, and pyrvinium pamoate) as broad-spectrum inhibitors according to their strong inhibition of replication by four CoVs at low-micromolar concentrations. Additionally, we found that emetine blocked MERS-CoV entry according to pseudovirus entry assays and that lycorine protected BALB/c mice against HCoV-OC43-induced lethality by decreasing viral load in the central nervous system. This represents the first demonstration of real-time bioluminescence imaging to monitor the effect of lycorine on the spread and distribution of HCoV-OC43 in a mouse model. These results offer critical information supporting the development of an effective therapeutic strategy against CoV infection. Currently, there is no approved therapy to treat coronavirus infection; therefore, broad-spectrum inhibitors of emerging and endemic CoVs are needed. Based on our high-throughput screening assay using a compound library, we identified seven compounds with broad-spectrum efficacy against the replication of four CoVs Additionally, one compound (lycorine) was found to protect BALB/c mice against HCoV-OC43-induced lethality by decreasing viral load in the central nervous system. This inhibitor might offer promising therapeutic possibilities for combatting novel CoV infections in the future.
Topics: Amaryllidaceae Alkaloids; Animals; Antiviral Agents; Cell Line; Coronavirus; Coronavirus OC43, Human; Drug Evaluation, Preclinical; Emetine; High-Throughput Screening Assays; Humans; Mice; Mice, Inbred BALB C; Middle East Respiratory Syndrome Coronavirus; Phenanthridines; Severe acute respiratory syndrome-related coronavirus
PubMed: 30918074
DOI: 10.1128/JVI.00023-19 -
Urology Practice Jun 2024Office administration of intradetrusor onabotulinumtoxinA is commonly used to treat overactive bladder. For preprocedure analgesia, either 50 mL 2% intravesical...
INTRODUCTION
Office administration of intradetrusor onabotulinumtoxinA is commonly used to treat overactive bladder. For preprocedure analgesia, either 50 mL 2% intravesical lidocaine instillation for 20 to 30 minutes or 200 mg oral phenazopyridine can be used. Phenazopyridine is associated with shorter appointment times and is noninferior to lidocaine for pain control in this setting. We performed a cost analysis of phenazopyridine vs lidocaine for analgesia before office intradetrusor onabotulinumtoxinA injection for the treatment of idiopathic overactive bladder.
METHODS
A health care sector-perspective cost analysis was performed. The following assumptions were made: (1) similar efficacy of each medication in providing adequate analgesia, (2) similar physician ease of performing the procedure with either analgesic, and (3) similar patient satisfaction with either analgesic. Average cost of medications, adverse reactions, nursing tasks, and office visit time were found in publicly available data. Sensitivity analyses were performed using TreeAge Pro 2021, R1 software.
RESULTS
Phenazopyridine is less costly compared to lidocaine per visit for office intradetrusor onabotulinumtoxinA injection ($827 vs $925). A difference of $98 per procedure provides a total annual cost savings of over $24 million if all procedures are performed with phenazopyridine instead of lidocaine. Sensitivity analysis showed that phenazopyridine remained less costly under most circumstances, and threshold analysis provided exact circumstances under which phenazopyridine is no longer cost saving.
CONCLUSIONS
Phenazopyridine provides cost savings compared to lidocaine for analgesia before office intradetrusor onabotulinumtoxinA injection for the treatment of idiopathic overactive bladder. If adopted by providers nationwide, phenazopyridine may reduce health care spending and minimize office visit time while maintaining patient pain control and satisfaction.
PubMed: 38913587
DOI: 10.1097/UPJ.0000000000000628 -
BMJ Case Reports Feb 2019
Topics: Eating; Female; Humans; Hypoxia; Methemoglobinemia; Middle Aged; Patient Education as Topic; Phenazopyridine; Urinary Incontinence, Urge
PubMed: 30772834
DOI: 10.1136/bcr-2018-227538 -
Clinical Practice and Cases in... May 2022As ketamine gains traction as an alternative to opiates in the treatment of chronic pain, ketamine-induced ulcerative cystitis is now being recognized as a complication...
INTRODUCTION
As ketamine gains traction as an alternative to opiates in the treatment of chronic pain, ketamine-induced ulcerative cystitis is now being recognized as a complication of its use. The first-line treatment is phenazopyridine, an over-the-counter medication for dysuria that historically has been known to cause methemoglobinemia. This report details the case of a patient presenting to the emergency department (ED) with methemoglobinemia.
CASE REPORT
A 66-year-old woman with a complicated medical history presented to the ED with anemia and hypoxia after extended use of phenazopyridine for treatment of ketamine-induced ulcerative cystitis. She was found to have methemoglobinemia secondary to phenazopyridine used to treat her ketamine-induced ulcerative cystitis, a previously undocumented sequelae of chronic ketamine use. She was admitted to the hospital for three days and made a full recovery.
CONCLUSION
This case highlights the need to suspect ketamine-induced ulcerative cystitis in patients who use ketamine chronically and be judicious in the use of phenazopyridine for symptom management to prevent life-threatening complications.
PubMed: 35701344
DOI: 10.5811/cpcem.2022.1.55277 -
European Review For Medical and... Sep 2016Overactive bladder is a syndrome of urinary frequency and urgency, with or without urge incontinence, in the absence of local pathological factors. Since multiple causes... (Meta-Analysis)
Meta-Analysis
OBJECTIVE
Overactive bladder is a syndrome of urinary frequency and urgency, with or without urge incontinence, in the absence of local pathological factors. Since multiple causes are responsible for OAB, it requires proper diagnosis and comprehensive management. For decades, flavoxate is a globally used and accepted molecule by the urologists and the general physicians for the symptomatic treatment of OAB. In spite of its extensive use in OAB, a meta-analysis of the available publications for efficacy, safety and tolerability of flavoxate has not been conducted. This paper evaluates the strength of evidence of clinical effectiveness of safety and tolerability of flavoxate in the symptomatic treatment of OAB.
METHODS
Review articles, original studies and case reports on MEDLINE, the Cochrane Library, Google Scholar, Scirus, internal repository, etc. were searched using the keyword "flavoxate". For the primary outcome, the comparative data of flavoxate versus comparator was extracted for following parameters - overall efficacy and its side effect profile. Similarly as for secondary outcome, data were extracted for flavoxate per se for overall efficacy, frequency, urinary incontinence, mixed incontinence, nocturia, unpleasant urination, stranguria and its side effect profile and were analyzed using Comprehensive Meta-Analysis (CMA) software version 2.0.
RESULTS
In the current meta-analysis, 43 relevant published studies were considered which clearly demonstrated that flavoxate had improved clinical efficacy than placebo, emepronium, propantheline, and phenazopyridine.
CONCLUSIONS
Amongst all the interventions studied, flavoxate was effective and well-tolerated, with almost negligible side effects, making it worthy of consideration for the treatment of OAB.
Topics: Dysuria; Flavoxate; Humans; Treatment Outcome; Urinary Bladder, Overactive; Urination; Urological Agents
PubMed: 27649675
DOI: No ID Found -
Obstetrics and Gynecology Dec 2016To compare different modalities to aid in the evaluation of intraoperative ureteral patency on cystoscopy in the postindigo carmine era. (Comparative Study)
Comparative Study Randomized Controlled Trial
OBJECTIVE
To compare different modalities to aid in the evaluation of intraoperative ureteral patency on cystoscopy in the postindigo carmine era.
METHODS
In a randomized controlled trial, participants undergoing pelvic surgery were randomized into one of four groups: saline distention (control), 10% dextrose distention, oral phenazopyridine, or intravenous sodium fluorescein. Our primary outcome was visibility of the ureteral jets. Secondary outcomes included surgeon satisfaction; adverse reactions including allergies, urinary tract infections, urinary retention, cystoscopy times, and ureteral obstruction; and delayed diagnosis. Participants were followed for 6 weeks. A sample size of 176 participants was planned to demonstrate a 30% difference in the visibility scale. All analyses were performed in an intention-to-treat fashion.
RESULTS
From February 25, 2015, through August 2015, 176 participants were enrolled; 174 completed the trial, and two did not undergo intervention. Forty-four participants were included in the phenazopyridine, dextrose, saline, and sodium fluorescein groups. Sodium fluorescein and 10% dextrose resulted in significantly improved visibility and satisfaction when compared with the control group (P<.001 and P=.004, respectively). Dextrose provided the highest satisfaction and phenazopyridine provided lowest, but visibility was not statistically different between the two groups (P=.101). Three ureteral obstructions were identified intraoperatively and none in the postoperative period. Mean total cystoscopy time varied between 4.0 and 4.8 minutes and postoperative urinary retention rate was 50% across all groups. Overall urinary tract infection rate was 24.1%, which was similar between interventions. There were no related adverse events.
CONCLUSION
Compared with the control, 10% dextrose and sodium fluorescein resulted in improved visibility and provided significantly more satisfaction in the evaluation for ureteral patency with no considerable increase in operative time or morbidity.
CLINICAL TRIAL REGISTRATION
ClinicalTrials.gov, https://clinicaltrials.gov, NCT02476448.
Topics: Administration, Intravenous; Administration, Oral; Aged; Attitude of Health Personnel; Cystoscopy; Female; Fluorescein; Fluorescent Dyes; Glucose; Gynecologic Surgical Procedures; Humans; Intraoperative Care; Intraoperative Complications; Middle Aged; Operative Time; Phenazopyridine; Prospective Studies; Ureter; Ureteral Obstruction; Urinary Retention; Urinary Tract Infections; Wounds and Injuries
PubMed: 27824741
DOI: 10.1097/AOG.0000000000001750 -
Urology May 2018To identify difficult to see ureteral orifices (UOs), urologists need a method to stain the urine. Phenazopyridine, a urinary analgesic which discolors the urine orange,...
OBJECTIVE
To identify difficult to see ureteral orifices (UOs), urologists need a method to stain the urine. Phenazopyridine, a urinary analgesic which discolors the urine orange, can be administered orally preoperatively. We evaluated the usefulness of phenazopyridine in identifying the UOs and optimal timing of administration.
METHODS
Adult patients undergoing endoscopic procedures at the Stratton VA were prospectively enrolled. Preoperative metabolic panels were reviewed. Exclusion criteria were renal insufficiency (creatinine clearance <50 mL/min), severe hepatitis or severe liver disease, glucose-6-phosphate dehydrogenase deficiency, previous hypersensitivity to phenazopyridine, or pregnancy. In phase 1, patients undergoing office flexible cystoscopy were administered 200 mg phenazopyridine the morning of the procedure. Because of the robust orange color of the urine, phase 2 was implemented. In phase 2, patients undergoing rigid cystoscopy in the operating room took 200 mg phenazopyridine at 7 PM the night before surgery. Upon entry into the bladder, UOs were identified and urine color was graded (0 = no dye, 1 = weak, 2 = moderate, and 3 = strong). Patients were assessed postoperatively for side effects.
RESULTS
Five patients were included in phase 1. The mean time from medication to cystoscopy was 153 minutes (range 17-304 minutes). One-third of patients had excretion of grade 3 orange urine that obscured inspection of the bladder mucosa. The study design was adjusted and we transitioned to phase 2. Twenty-three patients were enrolled in phase 2. The mean time from phenazopyridine dose to cystoscopy was 14 hours (range 13-17 hours). Seventy-three percent of patients had grade 2 efflux from the UOs.
CONCLUSION
Phenazopyridine can successfully identify UOs and can be administered as early as the evening before the procedure.
Topics: Aged; Aged, 80 and over; Color; Cystoscopy; Drug Administration Schedule; Female; Humans; Male; Middle Aged; Phenazopyridine; Ureter; Urine
PubMed: 29501712
DOI: 10.1016/j.urology.2018.02.023 -
Obstetrics and Gynecology Aug 2016To evaluate the usefulness of phenazopyridine for confirmation of ureteral patency during intraoperative cystoscopy. (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVE
To evaluate the usefulness of phenazopyridine for confirmation of ureteral patency during intraoperative cystoscopy.
METHODS
We conducted a randomized controlled trial comparing use of phenazopyridine with no medications for evaluation of ureteral patency during intraoperative cystoscopy in women undergoing pelvic surgery. The primary study outcome was time to visualize ureteral urine efflux. To detect a 3-minute difference with α of 0.05 using a two-sided, two-sample t test and β 0.80 required 98 patients equally divided into two groups.
RESULTS
A total of 104 women were randomized from April to December 2015. Patients in the treatment group tended to be older (P=.02); otherwise, study groups were similar. Time to visualize ureteral urine efflux did not differ between study groups with a mean time of 2 minutes 40 seconds (±2 minutes 38 seconds) in the control group and 2 minutes 53 seconds (±4 minutes 35 seconds) in the treatment group (P=.77). Regarding the surgeon survey, surgeons felt less frustrated and impatient in visualization of ureteral urine efflux in the treatment group compared with the control group (mean response 1.5±0.8 in treatment compared with 2.0±1.0 in control, P=.007), and surgeons felt that the cystoscopy took too long more often in the control than in the treatment group (1.7±0.9 in treatment compared with 2.1±1.0 in control, P=.02). Trial of void result differed significantly between groups with fewer patients in the treatment group failing a void trial (P=.04). There were no adverse events related to phenazopyridine use.
CONCLUSION
Preoperative phenazopyridine is a useful and cost-saving medication for use in planned cystoscopy for evaluation of ureteral patency.
CLINICAL TRIAL REGISTRATION
ClinicalTrials.gov, https://clinicaltrials.gov/, NCT02424149.
Topics: Adult; Aged; Aged, 80 and over; Attitude of Health Personnel; Coloring Agents; Cystoscopy; Female; Gynecologic Surgical Procedures; Humans; Intraoperative Care; Intraoperative Complications; Middle Aged; Phenazopyridine; Time Factors; Ureter; Wounds and Injuries
PubMed: 27399998
DOI: 10.1097/AOG.0000000000001472