Protocol may eliminate need for opioids after robot-assisted laparoscopic prostatectomy

Washington-More than 85% of patients undergoing robot-assisted laparoscopic prostatectomy (RALP) may not require opioid analgesia either immediately post-op, in hospital, or upon release, according to a recent study.

“Following RALP, we prescribe an antibiotic, stool softener, and anticholinergic medication at hospital discharge. Typically, patients take acetaminophen for discomfort when they get home. That appears to be adequate,” said first author Carson Wong, MD, chief of urology at University Hospitals Ahuja Medical Center, Beachwood, OH.

Dr. Wong initiated the protocol about 2 years ago when he assumed the position at Ahuja Medical Center and as medical director of the Center for Minimally Invasive and Robotic Surgery at Parma Community General Hospital, Parma, OH. He is also director of minimally invasive and robotic surgery at Southwest Urology, LLC, Cleveland.

“Intravenous acetaminophen became available, and we elected to prescribe it in combination with Toradol (ketorolac), a non-narcotic known to provide analgesia in stone patients. Some patients in our series had a history of chronic back pain that had been treated with narcotics, developing tolerance to opioid analgesics. Despite this, the majority of our patient cohort did not require opioids in the post-anesthesia care unit (PACU) or on the hospital floor,” said Dr. Wong, who presented the findings at the 2013 American College of Surgeons Clinical Congress in Washington.

Dr. Wong and his colleagues collected data on 69 consecutive patients who underwent RALP under general anesthesia administered as a balanced technique. The standardized aspect of the procedure included acetaminophen, 1,000 mg IV in a 15-minute infusion, and ketorolac, 30 mg IV prior to extubation. Acetaminophen was administered every 6 hours following surgery with ketorolac, 30 mg administered intravenously at 8-hour intervals. The patients were given a clear liquid diet and were ambulating by the evening of surgery. They were discharged following passage of flatus and evidence that a regular diet could be tolerated.

The study patients (median age, 62 years) had an American Society of Anesthesiologists Classification of 3 (functional limitation with controlled disease and no immediate danger of death). Mean operative time was 90 minutes with a mean estimated blood loss of 75 mL. Mean hospitalization was 22 hours, and mean urethral catheter duration was 5 days.

Many patients avoid opioid analgesia

Less than one-third-22 patients (31.9%)-received parenteral opioid analgesia in the PACU but required none on the hospital floor. More than half-39 patients (56.5%)-did not require parenteral nor oral opioid medication following the procedure or on the hospital floor. Patients received narcotic analgesia only if they requested it.

“This suggests that a major pelvic operation can be performed with minimal patient morbidity. This includes being able to avoid medications that have potential adverse effects that can delay patient recovery,” Dr. Wong told Urology Times.UT

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