Analgesics in RALP: Can we standardize?

Robot-assisted laparoscopic prostatectomy (RALP) has been reported now in multiple studies to result in less estimated blood loss, shorter hospital stay, and less pain compared to open radical prostatectomy (Curr Urol Rep 2011; 12:229-36; World J Urol 2012; 30:85-9; Int Braz J Urol 2008; 34:259-68; BJU Int 2009; 104:991-5; JAMA 2009; 302:1557-64). Postoperative pain is the subject of an article in this issue of Urology Times and warrants further discussion.

Previous studies have reviewed pain scores and analgesic use when comparing RALP to open surgery (Curr Urol Rep 2011; 12:229-36). D’Alonzo et al reported lower post-op pain scores and less morphine-equivalent opioid use with the robotic approach (J Clin Anesth 2009; 21:322-8). However, a standardized post-op analgesic pathway is lacking and would certainly be beneficial for those of us who frequently perform robotic procedures.

In this issue, Wong et al present their series of 69 patients undergoing RALP and noted that 57% required no opioids while in recovery or in the hospital. The authors used acetaminophen, 1,000 mg IV, and ketorolac, 30 mg IV, prior to extubation and then postoperatively while admitted overnight. They felt that, with this pathway, narcotics and the side effects associated with narcotics could frequently be avoided.

I certainly applaud the authors’ efforts and feel that such standardized algorithms can be very beneficial for practicing urologists. However, their study lacks an objective measure of pain (such as a Likert pain score) or explanation of why many of the patients did require narcotics.

In our practice, we have certainly found that many of the patients do not need narcotics, and we use a very similar algorithm, but cut the ketorolac dose in half if the operation was more bloody than usual. We do find, as the authors did, that patients with chronic back pain or other musculoskeletal issues will frequently ask for narcotics more frequently afterward.

Hopefully, with more patients enrolled in a study such as this one, confirmatory studies from other institutions, and a more granular review of patients who do require opioids postoperatively, we can develop an algorithm that most practicing robotic surgeons can standardize and adopt. I believe that, as we come under closer scrutiny to standardize our practices and report quality outcomes, such articles will become more and more important to optimize outcomes for our practices and our patients.UT

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