The Effect of Listening to Music During Percutaneous Nephrostomy Tube Placement on Pain,Anxiety,and Success Rate of Procedure: A Randomized Prospective Study

Abstract

Purpose:

To evaluate the effect of listening to music on pain, anxiety, and success of procedure during office-based percutaneous nephrostomy tube placement (PNTP).

Materials and Methods:

One hundred consecutive patients (age >18 years) with hydronephrosis were prospectively enrolled in this study. All patients were prospectively randomized to undergo office-based PNTP with (Group I, n = 50) or without music (Group II, n = 50). Anxiety levels were evaluated with State Trait Anxiety Inventory. A visual analog scale was used to evaluate pain levels, patient's satisfaction, and willingness to undergo the procedure. We also compared success rates of procedures.

Results:

The mean age, duration of procedure, and gender distribution were statistically similar between the two groups. The mean postprocedural heart rates and systolic blood pressures in Group I patients were significantly lower than Group II patients (p = 0.01 and p = 0.028, respectively), whereas preprocedural pulse rate and systolic blood pressure were similar. The mean anxiety level and mean pain score of Group I were significantly lower than those of Group II (p = 0.008 and p < 0.001, respectively). Group I also carried a significant greater mean satisfaction score and willingness to undergo repeat procedure compared with Group II (p < 0.001 for both). Success rate of nephrostomy tube placement in Group I was significantly higher compared with Group II (92% vs 66%, p = 0.04).

Conclusions:

The present randomized prospective study demonstrates that listening to music during office-based PNTP decreases anxiety or pain and increases success rate of procedure. As an alternative to sedation or general anesthesia, music is easily accessible without side effect and cost.

Introduction

Upper urinary tract obstruction (UUTO) is one of the most common conditions in urology practice. Malign or benign disorders such as ureteropelvic junction obstruction, ureteral or intrarenal stones, and ureteral or bladder tumor can cause UUTO. Urgent intervention might be necessary in these cases because continuous UUTO can cause impaired renal function, pyuria, pyelonephritis, or urosepsis.

Urgent drainage of obstruction can be performed by percutaneous nephrostomy tube placement (PNTP) or retrograde ureteral stent placement (USP). The choice of drainage type depends on indication, patient's comorbidities, and preferences of patient and physician. Although both PNTP and USP are equally effective,¹ retrograde USP generally requires regional or general anesthesia in an operating room, whereas PNTP can be performed under local anesthesia in an office setting. Furthermore, general anesthesia has some risks such as oropharyngeal irritation symptoms, airway trauma, cord paralysis, pulmonary aspiration, cardiovascular or cerebrovascular complications, and malignant hypothermia. Thus, PNTP under local anesthesia is more preferred by the physicians.

PNTP is performed by an experienced urologist or radiologist in an office setting. The procedure may not be well tolerated in some patients due to pain, discomfort and anxiety during nephrostomy tube passes through skin, abdominal layers and renal capsule, while under local anesthesia.² The pain is usually temporary. However, it can negatively affect the success of procedure due to decrease in patient cooperation by patient body movement and deep breathing.³

More recently, many trials have been published that listening to music decreases the anxiety and pain during invasive examination such as rigid or flexible cystoscopy and transrectal prostate biopsy.^4
–6 Music reduces perceptions of discomfort by activating the cingulo-frontal cortex, which coordinates attention shifting and pain modulation.⁷ To the best of our knowledge, there is no publication about the effect of listening to music on decreasing pain and anxiety during PNTP. The primary endpoint of this study was to compare anxiety and pain levels between with or wthout listening to music groups. Second, we evaluate the effect of listening to music on PNTP success rate.

Materials and Methods

Ethical approval for this study was obtained from the Institutional Review Board and Ethics committee. Between January 2015 and October 2016, totally 100 consecutive patients (age >18 years) with hydronephrosis requiring PNTP for variety indications (Table 1) were prospectively enrolled in this study. Patients were randomized into two groups. For randomization, block design was used. Group I consisted of 50 patients who were listening to their preferred music (any of the classical music, Turkish folk music, popular music, or foreign music) during PNTP through a headset, while Group II consisted of 50 patients who wore a headset without music during the procedure. Our exclusion criteria were bleeding diathesis, anticoagulant using, solitary kidney, hearing impairment, and cognitive and neurologic disorders. Informed written consent was taken from all patients. The trial was performed in accordance with the Declaration of Helsinki.

Table 1.

Indications for Percutaneous Nephrostomy Tube Placement

Indications	Group I (music) (n = 50), n (%)	Group II (no music) (n = 50), n (%)
Ureteral stone	28 (56)	25 (50)
Pyonephrosis	9 (18)	12 (24)
Ureteral stricture	2 (4)	1 (2)
Ureteropelvic junction obstruction	3 (6)	1 (2)
Pelvic malignancy caused obstruction	8 (16)	11 (22)

PNTP technique

All procedures were performed in an interventional room in an outpatient clinic, which is equipped with ultrasonography, local anesthetic agent, nephrostomy kits, and a full range of guidewires and needles. Prophylactic antibiotic (single oral dose ciprofloxacin 500 mg) was given to all patients before 1 hour of procedure. All patients were informed about the procedure and complications. All procedures were performed under ultrasound guidance at lateral position by a single experienced endourologist (E.O.). After cleaning the site of skin puncture with 10% povidone-iodine solution, local anesthesia was administered for all patients with 2% lidocaine. Targeted calix was punctured with an 18-gauge needle. A 0.035 hydrophilic guidewire was used to exchange the needle for dilatation when urine drainage was seen freely after removal of the stylet from the needle. The tract dilated as much as 8F and an 8F pigtail catheter was placed into the renal collecting system. All steps were done under ultrasound guidance. Catheter fixation was performed with two 2/0 silk suture.

Anxiety measures

Before (after patient informed about procedure technique and complications) and immediately after procedure, anxiety levels were evaluated with State Trait Anxiety Inventory (STAI), which can measure tension, worry, and apprehension that the respondent experiences at this moment or in current circumstances (state anxiety). A self-reported anxiety inventory comprised 20 questions. STAI score ranging from 20 to 80 and highest scores indicatE greater anxiety level.

Pain, satisfaction, and willingness to undergo the procedure measures

A visual analog scale (VAS) ranging from 0 to 10 was used to evaluate pain. Patients were assesed immediately after procedure and highest score indicate greater pain level. Furthermore, patient's satisfaction and willingness to undergo the procedure were evaluated by VAS.

Success rate of procedure

Success of procedure was evaluated in two stages. We separately recorded the success rate of calix puncture and nephrostomy tube placement.

Statistical analysis

For analysis, SPSS 16.0 (IBM Company, Chicago, IL) was used. Fisher's exact, chi-square, and t-test were used for comparisons. For statistical significance, p-value of <0.05 was accepted.

Results

The mean age was 47.3 ± 14.2 and the majority (73 patients) of patients were men. Duration of procedure was 21.2 ± 5.9 minutes. In all patients, before procedure, the heart rate, systolic blood pressure, and mean STAI score were 71.2 ± 5.4, 125.1 ± 9.1, and 37.3 ± 6.2, respectively. There were no statistically significant differences between two groups regarding mean age, gender distribution, duration of procedure, blood pressure, heart rate, and STAI score. The mean postprocedural systolic blood pressure was significantly lower in Group I patients, while there was no statistical significant difference between groups according to change in systolic blood pressure per patient (p = 0.028 and p = 0.15, respectively). The mean postprocedural heart rate and mean change in heart rates per patient were significantly lower in Group I patients (p = 0.01 and p = 0.003, respectively). The mean postprocedural pain (3.4 ± 1.4 vs 5.5 ± 1.5, p < 0.001) and STAI anxiety scores (41.1 ± 6.5 vs 44.7 ± 7, p = 0.008) were statistically significantly higher in Group II compared with Group I. The mean satisfaction score of Group I was significantly higher compared with Group II (5.9 ± 1.2 vs 4.5 ± 1.6, p < 0.001). Group I was significantly more willing to undergo a repeat PNTP than Group II (5.9 ± 1.4 vs 3.9 ± 1.5, p < 0.001). Our success rate of nephrostomy tube placement in Group I was significantly higher compared with Group II (92% vs 66%, p = 0.04), whereas success rates of calix puncture were comparable (96% vs 94%, p = 0.9). All comparisons are detailed in Table 2.

Table 2.

Patient's Demographics and Comparison of Preprocedural and Postprocedural Characteristics

	All patients	Group I (music) (n = 50)	Group II (no music) (n = 50)	p
Mean age, years	47.3 ± 14.2 (range: 19–74)	46.5 ± 14.6 (range: 22–71)	48.1 ± 13.8 (range: 19–74)	0.56
Male patients, %	73	76	70	0.64
Duration of procedure, minutes	21.2 ± 5.9 (range: 11–34)	21.9 ± 6.1 (range: 12–34)	20.5 ± 5.7 (range: 11–32)	0.29
Mean preprocedural systolic blood pressure (mm Hg)	125.1 ± 9.1 (range: 105–145)	123.4 ± 9.6 (range: 105–145)	126.8 ± 8.3 (range:110–145)	0.06
Mean preprocedural heart rate (beats/minute)	71.2 ± 5.4 (range: 59–88)	72.1 ± 5.5 (range: 61–85)	70.3 ± 5.3 (range: 59–88)	0.1
Mean preprocedural STAI score	37.3 ± 6.2 (range: 22–50)	37.7 ± 6 (range:22–50)	36.9 ± 6.4 (range:24–47)	0.47
Mean postprocedural systolic blood pressure (mm Hg)	128.2 ± 9.7 (range: 105–145)	126 ± 10.2 (range: 105–145)	130.4 ± 9.2 (range: 110–145)	0.028
Change in systolic blood pressure per patient, mean (mm Hg)	3.1 ± 4.9	2.6 ± 4.8	3.6 ± (4.9)	0.15
Mean postprocedural heart rate (beats/minute)	77.5 ± 8.3 (range: 61–105)	75.5 ± 8 (range: 61–100)	79.4 ± 8.7 (range: 63–105)	0.01
Change in heart rate per patient, mean (mm Hg)	6.3 ± 7.5	3.4 ± 6.9	9.1 ± 8.1	0.003
Mean postprocedural pain score (VAS)	4.5 ± 1.5 (range: 1–8)	3.4 ± 1.4 (range: 1–7)	5.5 ± 1.5 (range: 2–8)	<0.001
Mean postprocedural STAI score	42.9 ± 6.8 (range: 24–58)	41.1 ± 6.5 (range: 24–55)	44.7 ± 7 (range: 28–58)	0.008
Willingness to undergo procedure (VAS)	4.9 ± 1.5 (range: 1–8)	5.9 ± 1.4 (range: 3–8)	3.9 ± 1.5 (range: 1–7)	<0.001
Satisfaction (VAS)	5.2 ± 1.4 (range: 1–8)	5.8 ± 1.2 (range: 2–8)	4.5 ± 1.6 (range: 1–8)	<0.001
Success rate in calix puncture stage, %	95	96	94	0.9
Success rate of tube placement stage, %	79	92	66	0.04

STAI = State Trait Anxiety Inventory; VAS = visual analog scale.

Discussion

PNTP is one of the commonest procedures performed by radiologists and urologists with similar success rates.⁸ Especially with the identification of the interventional urology list, the number of interventional urological procedures (PNTP, nephrostogram, nephrostomy removal, anterograde or retrograde Double-J stent insertion, renal cyst aspiration or sclerotization, and flexible cystoscopy) performed by urologists at an office setting independent of radiologists has been increased.⁹

PNTP procedure is well tolerated by most patients. However, each patient has a different pain threshold or different pain tolerance. Especially, when puncture is performed too posterior or medially, it will lead to more pain as the nephrostomy tube passes through the paraspinal muscles.² Kocuoglu and coworkers compared the success rates of two different percutaneous nephrostomy techniques.³ All procedures were performed by urologists. PNTP procedures were performed under local anesthesia in prior 42 patients. Their tube placement success rate was 69.1%, while calix puncture success rate was 100%. Due to the previous low success rate, they decided to perform the procedure under local anesthesia supplemented by deep sedation (Propofol) for following patients. They detected a dramatically increased tube placement success rate (95.1%). They emphasized that PNTP success rate is low in patients who had anxiety and who suffered pain due to increased frequent and deep breathing.

Although PNTP procedure has a high success rate when the procedure is performed under general anesthesia or sedation, the sedative agent has several side effects on cardiovascular, respiratory, gastrointestinal, dermatologic, and neurologic systems.^10,11 Furthermore, the price of Propofol is approximately 7$ in our country per sedation performed. When the patient is awake, immobilization and uneasiness due to visual and auditory stimuli may increase anxiety levels even if procedures are performed under local anesthesia.¹² As an alternative modality, music has anxiolytic effects and has been applied to ameliorate stressful interventions.¹³ Previous studies showed that listening to music activates cingulo-frontal cortex to mitigate perceived pain effectively through pain modulation and attention shifting.^7,14 In addition, music is cheap and has no side effects.

To date, a few trials have been published on nonpharmacologic anxiolytic effect of listening to music in the urologic area.^4
–6 Zhang and coworkers evaluated the effect of listening to preferred music (by patient) on male patient pain and anxiety during flexible cystoscopy.⁴ They randomized all patients into two groups (listening to music during flexible cystoscopy and without music) and compared pain (VAS) and anxiety (STAI) scores. The mean postprocedural STAI score (34 in music group, 39 in without music group, p < 0.001), mean pain score on VAS (1.63 in music group, 2.53 in without music group, p < 0.001), and postprocedural pulse rate (76 vs 79, respectively, p = 0.002) were statistically significantly lower in the music group. In another study, Raheem and coworkers supported Zhang's study. They reported that listening to music during office-based flexible cystoscopy has a positive effect on decreasing anxiety and pain.⁶ Furthermore, the effect of music during transrectal prostate biopsy was assessed by Chang and coworkers.⁵ They compared classical music and no-music groups regarding patient anxiety, pain, and dissatisfaction. The mean anxiety level, mean pain score, and dissatisfaction score were significantly lower in the no-music group than those of classical music group (p = 0.001, p = 0.003, and p = 0.007, respectively).

Although there were previous trials on listening to music during several office-based procedures, no study has investigated whether music decreases perceptions of pain and anxiety among patients undergoing the PNTP procedure. Our results were comparable with previously published studies and demonstrate that listening to music during PNTP decreases pain and anxiety. Differently, we compared the success rates of nephrostomy tube placement between two groups and observed that listening to music during procedure has a positive effect on the nephrostomy tube placement success rate. The nephrostomy tube placement success rate was higher in the music group than the no-music group, despite calix puncture success rates being similar in both groups. The reason for this difference is probably that local anesthesia is equally effective in reducing the pain in all patients until the calix puncture step, and the no-music group felt more pain, discomfort, and anxiety in subsequent steps such as dilatation and nephrostomy placement. The procedure was terminated in patients with severe pain and who cannot tolerate the procedure. All these patients were consulted at the interventional radiology department and all PNTP procedures were performed effectively under sedation anesthesia on the following day.

Our study has several limitations. We did not evaluate the pain feeling during each step of the procedure separately, such as injection of local anesthetic agent, needle passing through muscles layers and renal capsule, targeted calix puncture, and nephrostomy tube placement. The mean postprocedural systolic blood pressure was significantly lower in the music group. However, there was no statistically significant difference between groups according to change in systolic blood pressure per patient. When we questioned medical history of our patients, 12 and 6 patients have hypertension history in the no-music and music group, respectively. Thus, we could exclude those patients from study. Another important limitation is that we could record the preprocedural pain score because the evaluation of change in pain scores may be a more important aspect than absolute postprocedural pain scores.

Conclusions

Despite these limitations, the present randomized prospective study is the first study to analyze whether listening to music during PNTP ameliorates feelings of anxiety and pain and increases the success rate of procedure. Music is easily accessible without side effects and cost. Thus, we support that music can be offered during the office-based PNTP procedure to reduce patient's anxiety and pain.

Footnotes

Author Disclosure Statement

No competing financial interests exist.

Abbreviations Used

References

Türk

, Petřík

, Sarica

, et al. EAU guidelines on diagnosis and conservative management of urolithiasis. Eur Urol, 2016; 69:468–474.

Dagli

, Ramchandani

. Percutaneous nephrostomy: Technical aspects and indications. Semin Intervent Radiol, 2011; 28:424–437.

Kocuoglu

, Alan

, Malkoc

, et al. A different approach to the percutaneous nephrostomy by urologists. Actas Urol Esp, 2012; 36:613–619.

Zhang

, Wang

, Xu

, et al. Music reduces panic: An initial study of listening to preferred music improves male patient discomfort and anxiety during flexible cystoscopy. J Endourol, 2014; 28:739–744.

Chang

, Ohb

, Lee

, et al. Listening to music during transrectal ultrasound-guided prostate biopsy decreases anxiety, pain and dissatisfaction in patients: A pilot randomized controlled trial. Urol Int, 2015; 94:337–341.

Raheem

, Mirheydar

, Lee

, et al. Does listening to music during office-based flexible cystoscopy decrease anxiety in patients: A prospective randomized trial. J Endourol, 2015:29; 791–796.

Kondo

, Morishita

, Osaka

, et al. Functional roles of the cingulo-frontal network in performance on working memory. Neuroimage, 2004; 21:2–14.

Skolarikos

, Alivizatos

, Papatsoris

, et al. Ultrasound-guided percutaneous nephrostomy performed by urologists: 10-year experience. Urology, 2006; 68:495–499.

Masood

, Ismail

, El-Husseiny

, et al. ‘An interventional urology list’—A novel concept for UK urological services. Ann R Coll Surg Engl, 2011; 93:27–30.

10.

Sebel

, Lowden

. Propofol: A new intravenous anesthesic. Anesthesiology, 1989; 71:260–277.

11.

Robinson

, Ebert

, O'brien

, et al. Mechanisms whereby propofol mediates peripheral vasodilatation in humans. Sympathoinhibiton or direct vascular relaxation?. Anesthesiology, 1997; 86:64–72.

12.

Knight

, Rickard

. Relaxing music prevents stress-induced increases in subjective anxiety, systolic blood pressure, and heart rate in healthy males and females. J Music Ther, 2001; 38:254–272.

13.

Lee

, Chan

, Wong

, et al. Can visual distraction decrease the dose of patient-controlled sedation required during colonoscopy? A prospective randomized controlled trial. Endoscopy, 2004; 36:197–201.

14.

Valet

, Sprenger

, Boecker

, et al. Distraction modulates connectivity of the cingulo-frontal cortex and the midbrain during pain an fMRI analysis. Pain, 2004; 109:399–408.