Effect of Cyclooxygenase-2 Inhibitors in Double J Stent Removal under Local Anesthesia  

Rulianov Rulianov1, Jumadi Santoso2, Aryo Teguh Abriansyah2, and Safendra Siregar1

1. Department of Urology, Faculty of Medicine Universitas Padjadjaran, Hasan Sadikin Academic Medical Center, Indonesia 

2. Department of Urology, Faculty of Medicine, Universitas Padjadjaran, Soekardjo Hospital, Tasikmalaya, Indonesia 

 

Correspondence to: Dr. Rulianov Rulianov; email: rulianov@gmail.com 

Received:  4 April 2021; Revised:  24 June 2021; Accepted:  30 Jun 2021; Available online: 16 Aug 2021

Abstract 

Introduction: Celecoxib is a selective cyclooxygenase-2(COX-2) inhibitor that can reduce the inflammatory process during double J (DJ) stent removal procedure. This study aimed to determine the differences in pain levels in patients undergoing DJ stent removal under local anesthesia by oral administration of celecoxib before the procedure. Materials and methods: A total of 46 male patients who underwent removal of DJ stent under local anesthesia from December 2019 to February 2020 were included. Patients were divided into two groups according to oral administration of celecoxib 3 hours before the procedure. The visual analog scale (VAS) and side effects were compared between the two groups. Results: The mean patient age was 50.26 ±  14.92 years in the group without celecoxib and 50.35 ±  15.61 years in the group with celecoxib. The mean intra- operative VAS score was significantly higher in the  group without celecoxib (6.87 ± 1.51) thanthat in the group with celecoxib (3.74 ± 1.65) (p=0.04). The VAS scores on the first day after the procedure were 2.08 ±  0.79 and 1.34 ± 0.98 in the groups without and with celecoxib, respectively (p=0.53). Only 1 patient had nausea as side effect of celecoxib. Conclusion: Celecoxib can reduce pain during DJ stent removal. 

Keywords:  Cyclooxygenase-2 inhibitor, double J stent removal, local anesthesia  


Ann Afr Surg. 2021 ; 18(4): 220-224 
DOI: http://dx.doi.org/10.4314/aas.v18i4.5
Conflicts of Interest: None
Funding: None
© 2021 Author. This work is licensed under the Creative Commons Attribution 4.0 International License 

Introduction

Ureter stent placement is commonly performed in urological surgery both in open surgery and endourology(1,2). Its indications for use have continued to grow in the last 10 years(2). In general, temporary placement of ureteric stents in the ureter to help drain the urinary tract, thus preventing ureteral stenosis and giving the wound suture time to heal(1,3,4). Among various ureteric stents available in the market, the double J (DJ) stent is often used(4). This stent was first introduced by Finney in 1978, and both of its ends are shaped like a letter J in order to prevent displacement after placement in the ureter(2). However, the DJ stent has several complications(1,2), such as stent encrustation, migration, and fragmentation (1). Research shows that, to avoid such complications, the optimal duration to use a DJ stent is 6 to 8 weeks(1,2). Therefore, ureteral stent removal is a crucial step in patient management. In patients with stent related complications, 64% had symptoms after stent removal (pain, hematuria, frequency, urgency, or fever), and among those with symptoms, 60% experienced pain or discomfort(1,5). 

A variety of techniques are used in ureteral stent removal, starting from the use of a cystoscope, direct pulling on the thread in the DJ stent, using a catheter that is knotted at the end, and using a DJ stent that is specially designed to have a magnet at the tip(4). 

Among these techniques, the use of a rigid cystoscope retrograde through the urethra under general anesthesia is the technique often used when removing ureteral stents(3).The end of the DJ stent is clamped using a special clamp that is inserted into the cystoscope and then pulled out. Even though this procedure only takes a short time, it still requires surgical personnel, anesthetic team, in-room care, sterilization of equipment, operating rooms, anesthesia equipment, and so on; all of which contribute to its high costs(4).To reduce these costs, DJ stent release can be switched from general anesthesia to using local anesthetic(6). 

The local anesthetic used in this procedure is a lubricating jelly containing lidocaine that is inserted into the urethra(7). A flexible cystoscope with a smaller diameter is a better alternative to a rigid cystoscope. However, this tool is not available worldwide. A common complication of the DJ stent release in post-procedure patients is pain, which is believed to originate from the production of prostaglandins in the tissue due to trauma caused by the entry of rigid cystoscopy into the urethra(3,7). 

The cyclooxygenase (COX) enzyme has the role of converting unsaturated arachidonic acid fats into prostaglandins. COX has two isozymes, namely COX- 1 and COX-2, and 60% of their amino acid sequences are the same, but they have different gene encoding, location, and receptors for non-steroidal anti- inflammatory drugs (NSAIDs). COX-1 is found in almost all tissues that produce prostaglandins in small amounts for physiological functions. Meanwhile, COX-2 is produced in response to growth and inflammatory factors(8,9). 

Trauma due to surgical processes triggers the production of the COX enzyme leading to the production of prostaglandins. Prostaglandins increase the sensitivity of nociceptors (pa