JOURNAL OF ENDOUROLOGY Volume 28, Number 5, May 2014 ª Mary Ann Liebert, Inc. Pp. 544–548 DOI: 10.1089/end.2013.0783
Pain and Analgesic Use After Robot-Assisted Radical Prostatectomy Solomon L. Woldu, MD, Aaron C. Weinberg, MD, Ari Bergman, MD, Edan Y. Shapiro, MD, Ruslan Korets, MD, Piruz Motamedinia, MD, and Ketan K. Badani, MD
Abstract
Purpose: While robot-assisted radical prostatectomy (RARP) is associated with shortened convalescence and decreased blood loss over open prostatectomy, little objective data is available regarding postoperative pain/ discomfort and use of analgesic medications after RARP. We sought to examine these parameters in a contemporary cohort. Patients and Methods: From 2011 to 2013, patients undergoing RARP were prospectively enrolled in a study to examine various pain parameters and carefully monitor opiate and other analgesic medication use while the patient recovered in the hospital. After discharge, the patients were asked to fill out a daily questionnaire regarding their pain parameters and self-report opiate usage. All questionnaires were based on the Wong-Baker FACES pain rating scale (0–10). Opiate dosages were converted to the approximate oral morphine sulfate equivalent dose (MSE). Results: A total of 60 patients, mean age 61 years, were enrolled in the study, underwent RARP, and completed follow-up questionnaires. None had a history of chronic narcotic use. Intraoperative opiate use was 94.1 mg MSE. There were 73.3% who received immediate postoperative ketorolac. After RARP, the main source of pain/discomfort was abdominal/incisional, followed by urethral catheter-related, penile, and bladder spasmrelated discomfort. Abdominal pain was generally moderate for most patients and decreased significantly after about 4 days. Penile and urethral catheter-related discomfort was mild throughout the study period. Opiate analgesic medication use quickly decreased as the subjective pain scores improved. Conclusions: After RARP, most patients experience mild/moderate abdominal discomfort, which improves steadily over several days. There is also a quick decline in the average opiate pain medication use that corresponds to the subjective improvement in pain symptoms. This information is useful for clinicians counseling patients on the pain associated with RARP and can serve as a reference to compare the convalescence associated with the other options for treatment of patients with localized prostate cancer. Introduction
P
rostate cancer can be managed via a variety of strategies, including extirpative and ablative surgery, radiation therapy, or even conservatively with active surveillance in select low-risk patients. Given the relative lack of clear data to suggest cancer-specific outcome differences in certain groups of patients with localized prostate cancer treated by any of the above-mentioned, patients and their physicians are left with a variety of secondary factors to consider when making the decision between available treatment options for their prostate cancer.1 For a patient who is confronted with this difficult decision, one of the most important factors weighing against prostatectomy vs the other treatment strategies is the potential postoperative pain and convalescence associated with surgery.
Within the broad category of extirpative surgery, there are a variety of approaches to radical prostatectomy, including open prostatectomy, which can be performed via a retropubic or perineal approach, laparoscopic prostatectomy, and most commonly now via robot-assisted radical prostatectomy (RARP). Since the advent of RARP in 1999, there has been rapid adoption of this approach that now represents about 80% of all prostatectomies performed in the United States.2 While proponents of RARP suggest a variety of advantages with the use of a robot for pelvic surgery, including reduced blood loss, reduced transfusion requirements, improved dexterity of instruments, one of the main advantages appears to be a decreased convalescence and improved postoperative pain.2–4 The majority of patients at high-volume centers are discharged on the first postoperative day.5
Department of Urology, Columbia University Medical Center, New York, New York.
544
PAIN AND ANALGESIC USE AFTER RARP
Despite how common the procedure has become, there is little objective data on postoperative convalescence after RARP. We performed a prospective study in a modern cohort of patients undergoing RARP to provide future patients and clinicians counseling patients on treatment options for prostate cancer with objective data on what they might reasonably expect after undergoing RARP. Patients and Methods
With Institutional Review Board approval from Columbia University Medical Center, patients from 2011 to 2012 with localized prostate cancer undergoing transperitoneal RARP were prospectively enrolled in a study to examine various pain parameters and carefully monitor opiate and other analgesic medication use while they recovered in the hospital and after discharge. Patients with an opiate allergy, chronically taking opiates, with a history of a pain syndrome, or with a history of drug or opiate abuse were excluded. Anesthesiologists were not involved in the study and did not deviate from their standard intraoperative or immediate postoperative analgesic protocols. No patients received a neuraxial block. RARP was performed by an experienced robotic surgeon (KKB) using the daVinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA). The camera trocar was placed just to the left of the umbilicus and was extended at the conclusion of the procedure to allow for specimen extraction. This site was then closed with interrupted figureof-eight sutures. All skin incisions were infiltrated with 10 to 20 mL of 0.25% bupivacaine subcutaneously and closed using subcutaneous absorbable sutures. After the operation, physicians caring for the patient administered questionnaires related to the patient’s perceived pain from four anatomic sites: Abdominal or incisional pain, urethral catheter-related pain, penile pain, and bladder spasm-related pain. The questionnaires were based on the Wong-Baker FACES Pain Rating Scale, which is a visual analog scale on which patients record their perception of pain on a 0 to 10 point scale, with 0 representing ‘‘no hurt’’ and 10 representing ‘‘hurts worst.’’6 After the patients arrived in the postoperative recovery unit, the questionnaires were administered at 30 minutes, 90 minutes, 6 hours, 12 hours, 18 hours, and 24 hours postoperatively. All patients were discharged on postoperative day 1, and after discharge, the patients were asked to fill out the same questionnaire regarding their pain parameters on a daily basis for 9 days until they were seen for a follow-up appointment and catheter removal. All opiate and analgesic medication was carefully recorded via the electronic medication dispensation system at our institution, which does not allow for any medication to be administered to a patient without a nursing or anesthesia record of that medication. Medications that were recorded included all opiate analgesics, nonsteroidal anti-inflammatory medications (in the form of ketorolac 30 mg or 15 mg intravenous [IV]), and anticholinergic medications (in the form of oral [PO] oxybutynin 5 mg). Patients were all given the standard postoperative orders for RARPs at our institution, which included acetaminophen 325 mg PO, 1 tablet every 4 to 6 hours for a pain score 1 to 3 on a 10-point scale; acetaminophen/codeine 325 mg/30 mg PO, 1 tablet every 4 to 6 hours for a pain score 4 to 6 on a 10point scale; acetaminophen/codeine 325 mg/30 mg PO, 2
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tablets every 4 to 6 hours for pain score 7 to 10 on a 10-point scale; and hydromorphone 1 mg IV every 3 hours for breakthrough pain. No patient received orders for standing opiate medication. Patients had a standing order for postoperative ketorolac IV (15 mg or 30 mg) every 6 to 8 hours if they had normal renal function and no operative contraindication. For those who experienced bothersome bladder spasms, anticholinergic medications were given on an as needed (PRN) basis in the form of oxybutynin 5 mg PO every 8 hours. On discharge, patients were typically given a prescription for acetaminophen/codeine 325 mg/30 mg PO, 1 to 2 tablets every 4 to 6 hours PRN. Once at home, in addition to filling out pain questionnaires, they were also asked to self-report opiate use on a daily basis. While the above analgesic medications and dosages represent our standards after RARP, the physicians taking care of the patient were at liberty to deviate from these standards if deemed necessary. All deviations from the standard protocol were recorded and reflected in the results of our analysis. To facilitate analysis, dosages of the various forms of opiate analgesics were converted to the approximate oral morphine sulfate equivalent dose (MSE).7 Because urologists are likely not to be familiar with MSE interpretation, we also converted from MSE to tablets of acetaminophen/ codeine in which 1 tablet of acetaminophen/codeine 325 mg/ 30 mg has the approximate equivalent opiate dosage of 4.5 mg MSE.7 Statistical analysis was performed using SPSS version 21.0 (IBM Corporation, Armonk, NY). Results
A total of 60 patients consented to the study and completed follow-up questionnaires. The mean age was 60.8 years (range 47–72 years). The mean prostate-specific antigen level was 6.2 ng/dL (range 0.9–24.0 ng/dL). The average body mass index was 27.8 (range 18.8–40.0). Four (6.7%) patients had a history of diabetes, 1 (1.7%) patient had a history of peripheral vascular disease. As per our exclusion criteria, no patients had a history of chronic opiate use, pain syndrome, or drug abuse. All patients underwent an uncomplicated RARP and were discharged on postoperative day 1. The mean total operative time was 186 minutes (range 150–210 min; Table 1). There were no readmissions during the study period. Immediately after RARP, the main source of pain/discomfort was abdominal, followed by catheter-related, penile, and bladder spasm-related discomfort. Figure 1 illustrates the severity and patterns of the different sources of pain after RARP. Patients reported a mean – standard deviation (SD) abdominal pain of 3.46 – 2.37 within the first 24 hours after surgery. This level of pain remained relatively constant for the first 4 days after discharge with a mean – SD score of 3.35 – 2.23. After the 4th postdischarge day, the level of pain began to decline steadily with a mean – SD score of 2.00 – 1.73 for postdischarge days 5 to 9 and reaching a nadir mean – SD pain score of 1.5 – 1.2 on the final 9th day of the study (Table 2). Patients reported the urethral catheter was associated with a mean – SD pain score of 1.27 – 1.63 within the initial 24 hours after surgery and rose slightly to a mean – SD of 2.36 – 2.34 (range 0–9) for up to 9 days after discharge. Similarly, penile pain was also reported within the initial 24 hours after surgery as low with mean – SD pain scores of
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Table 1. Patient Characteristics and Opiate Medication Use
Baseline clinical characteristics Age (years) BMI Diabetes PVD History of chronic narcotics use PSA (ng/mL) Operative time (min) Preoperative Gleason score 6 7 ‡8 Intraoperative medications Opiates (mean, mg MSE) Inpatient medications Periurethral lidocaine jelly use (%) Antimuscarinic use (%) Antimuscarinics (# doses of oxybutynin 5 mg) Opiates (mean, mg MSE) IV ketorolac use IV ketorolac (mean mg) Postdischarge medications Total opiates (mean, mg MSE)
Mean – SD
Range
60.8 27.8 4 (6.7%) 1 (1.7%) 0 (0%) 6.2 186
47–72 18.8–40.0
0.9–24.0 150–210
19 (31.7%) 34 (56.7%) 7 (11.7%) 94.1 – 39.6
7.5–215.0
7 (11.7%) 17 (28.3%) 0.83
0–10.0
41.2 – 45.5 44 (73.3%) 49.5 – 34.9
0–120.0
58.6 – 59.5
0–357.0
FIG. 1. Pain from various sources after robot-assisted radical prostatectomy.
0–182.0
SD = standard deviation; BMI = body mass index; PVD = peripheral vascular disease; PSA = prostate-specific antigen; MSE = morphine sulfate equivalent; IV = intravenous.
1.57 – 2.04 (range 0–10), and this rose while the patient recovered at home with mean pain scores from 1.93 (range 0–8, SD 2.33). Penile and catheter-related pain surpassed abdominal pain as the primary source of discomfort on postdischarge days 5 and 7, respectively. Bladder spasm-associated pain was initially low, with a mean – SD reported pain score of 0.84 – 2.28, but also rose slightly over the course of the postdischarge convalescence to a mean pain score of 1.86 – 2.63 and 1.58 – 2.49, for postdischarge days 1 to 4 and 5 to 9, respectively. The mean intraoperative opiate use was 94.1 mg MSE (range 7.5–215 mg, SD 39.6 mg). While recovering in the hospital for 24 hours, the mean inpatient opiate use was 41.2 mg MSE (range 0–182 mg, SD 45.5 mg). Forty-four (73.3%) patients received immediate postoperative ketorolac. Lidocaine jelly 2% was applied topically to the penile meatus for catheter-related discomfort in 7 (11.7%) patients. Seventeen (28.3%) patients received anticholinergic medications for pain associated with bladder spasms.
Once discharged from the hospital, the mean opiate use was 14.3 mg (range 0–45 mg, SD 9.1 mg) on the 1st postdischarge day and steadily decreased to 3.25 mg (range 0–45 mg, SD 7.7 mg) on the 9th day post-discharge. This corresponds to patients taking an average of 3.2 tablets of acetaminophen/codeine 325 mg/30 mg on the 1st discharge day and 0.7 tablets on the 9th discharge day (Fig. 2). The total opiate use after discharge from the hospital was 68.5 mg MSE (range 0–357 mg), which corresponds to 15.2 tablets of acetaminophen/codeine 325 mg/30 mg (range 0–79 tablets). Discussion
One of the proposed benefits of the adoption of the da Vinci Surgical System for RARP is decreased postoperative pain compared with open radical prostatectomy, but there is limited prospective data on what a patient undergoing RARP might reasonably expect in terms of pain and requirement of analgesic immediately after surgery and in the first week after recovering from the operation.8 Studies that indirectly attempt to address this question are typically in the context in trial of an analgesic technique vs placebo. In a study examining the effects of transversus abdominis plane block vs placebo on pain within 24 hours after open retropubic prostatectomy, the pain levels in the placebo arm were higher on average than in our group (4–6 on 10 point scale), but opiate requirements were generally similar at 45.5 mg MSE within
Table 2. Pain After Robot-Assisted Radical Prostatectomy (10-Point Pain Scale) Source of pain (Mean – SD) Time interval
Abdominal
Catheter-related
Penile
1st 24 hours postoperatively Days 1–4 after discharge Days 5–9 after discharge
3.46 – 2.37 3.35 – 2.23 2.00 – 1.73
1.27 – 1.63 2.25 – 2.03 2.46 – 2.59
1.57 – 2.04 1.88 – 2.21 1.98 – 2.44
SD = standard deviation.
Bladder spasm 0.84 – 2.28 1.86 – 2.63 1.58 – 2.49
PAIN AND ANALGESIC USE AFTER RARP
FIG. 2. Opiate analgesic use after robot-assisted radical prostatectomy. the first 24 hours after the operation.9 In another study in men undergoing RARP, patients were randomized to intravesical ropivacaine vs placebo and within the first 24 hours postoperatively, the authors reported the 20 patients in the placebo arm had similar mean pain scores and opiate requirements to those reported in our study.10 Webster and coworkers11 compared pain and opiate use after open prostatectomy and RARP and found lower mean pain scores (1.8 on 10-point scale) and opiate use (22.4 mg MSE) than in our cohort, but limited their analysis to the initial 24 hours after the operation and 2 weeks after the operation. Our study adds to the limited literature on this subject with increased sample size and longer careful follow-up, not just within the hospitalization period but beyond—once the patient is discharged home until the urethral catheter was removed. We feel this information is valuable in counseling patients about their treatment options after a diagnosis of localized prostate cancer, because the anxiety of potential pain associated with surgery is certainly a factor that weighs into a patient’s decision-making process. Our results indicate that the main source of discomfort within the first 5 days postRARP will most likely be from the abdomen and associated with the robotic arm port site incisions. The abdominal pain is relatively mild—on average rated 3 to 4 of 10 on a pain scale, and then decreases to below 2 of 10 within a week after the operation. While initially low, pain associated with the urinary catheter, penile pain, and pain associated with bladder spasms become a significant source of discomfort and even overtakes abdominal pain on the pain rating scale after about 5 to 6 days after the operation. Opiate analgesic use is predictably high during the short hospitalization, but declines precipitously as the patient recovers at home. On the first day at home, average opiate use is equivalent to about 3 to 4 tablets of acetaminophen/codeine 325 mg/30 mg. On average, after just 4 days of recovery, patients are taking fewer than 2 tablets of acetaminophen/codeine 325 mg/30 mg within a 24-hour cycle. Although this is a carefully coordinated and prospective study, there are several limitations that should be consid-
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ered. This study focused exclusively on robot-assisted prostatectomy performed by a single surgeon, which did not allow for direct comparison with open prostatectomy. Nonetheless, it is still relevant because the robotic approach has largely supplanted open surgery in the United States and we find that our patients are choosing between RARP and nonsurgical treatment options rather than considering options within extirpative surgery. Although we made a distinction between penile pain, catheter-related pain, and bladder spasm-related pain, it may be difficult for some patients to differentiate these different sources clearly in all cases. As is the case in any subjective questionnaire, the study participants have different pain thresholds, and this makes extrapolation difficult to an individual patient. Our study could have been improved if we had included questions related to how the pain after RARP interferes with the patient’s activities of daily living. Nonetheless, we think this study will give physicians an objective tool in counseling patients who are considering undergoing RARP but have reasonable concerns about what they may expect during their period of convalescence. Conclusions
RARP has been rapidly adopted as the primary surgical treatment of patients with localized prostate cancer for a variety of reasons, one of which is decreased pain postoperatively and a shorter convalescence period. Despite this, RARP is still abdominal surgery, and many patients have quite reasonable concerns about what to expect after surgery. Our study indicates that the abdominal pain is modest after the procedure and in most cases adequately controlled with a modest amount of opiate analgesics for the first 4 days after surgery. After 5 to 7 days, abdominal pain and opiate use declines significantly and is actually less bothersome than the discomfort associated with the penis and urethral catheter. This information should be useful in counseling patients on the merits of RARP vs other less invasive therapies for prostate cancer. Disclosure Statement
No competing financial interests exist. References
1. Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 2007;177:2106–2131. 2. Pilecki MA, McGuire BB, Jain U, et al. National multiinstitutional comparison of 30-day postoperative complication and readmission rates between open retropubic radical prostatectomy and robot-assisted laparoscopic prostatectomy using NSQIP. J Endourol 2014. Epub ahead of print. 3. D’Alonzo RC, Gan TJ, Moul JW, et al. A retrospective comparison of anesthetic management of robot-assisted laparoscopic radical prostatectomy versus radical retropubic prostatectomy. J Clin Anesth 2009;21:322–328. 4. Ficarra V, Novara G, Artibani W, et al. Retropubic, laparoscopic, and robot-assisted radical prostatectomy: A systematic review and cumulative analysis of comparative studies. Eur Urol 2009;55:1037–1063. 5. Patel HR, Linares A, Joseph JV. Robotic and laparoscopic surgery: Cost and training. Surg Oncol 2009;18:242–246. 6. Wong DL, Baker CM. Pain in children: Comparison of assessment scales. Pediatr Nurs 1988;14:9–17.
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7. Twycross RG, et al. Hospice and palliative care formulary USA. 2006, Nottingham: palliativedrugs.com. xxx, 467. 8. Tewari A, Srivsatava A, Menon M. Members of the VIP team. A prospective comparison of radical retropubic and robot-assisted prostatectomy: Experience in one institution. BJU Int 2003;92:205–210. 9. Elkassabany N, Ahmed M, Malkowicz SB, et al. Comparison between the analgesic efficacy of transversus abdominis plane (TAP) block and placebo in open retropubic radical prostatectomy: A prospective, randomized, doubleblinded study. J Clin Anesth 2013;25:459–465. 10. Fuller A, Vanderhaeghe L, Nott L, et al. Intravesical ropivacaine as a novel means of analgesia post-robot-assisted radical prostatectomy: A randomized, double-blind, placebocontrolled trial. J Endourol 2013;27:313–317. 11. Webster TM, Herrell SD, Chang SS, et al. Robotic assisted laparoscopic radical prostatectomy versus retropubic radical prostatectomy: A prospective assessment of postoperative pain. J Urol 2005;174:912–914.
WOLDU ET AL.
Address correspondence to: Solomon L. Woldu, MD Department of Urology Columbia University Medical Center Herbert Irving Pavilion, 11th Floor 161 Fort Washington Avenue New York, NY 10032 E-mail: [email protected]
Abbreviations Used IV ¼ intravenous RARP ¼ robot-assisted radical prostatectomy MSE ¼ morphine sulfate equivalent dose PO ¼ per os PRN ¼ pro re nata SD ¼ standard deviation
Pain and Analgesic Use After Robot-Assisted Radical Prostatectomy Solomon L. Woldu, MD, Aaron C. Weinberg, MD, Ari Bergman, MD, Edan Y. Shapiro, MD, Ruslan Korets, MD, Piruz Motamedinia, MD, and Ketan K. Badani, MD
Abstract
Purpose: While robot-assisted radical prostatectomy (RARP) is associated with shortened convalescence and decreased blood loss over open prostatectomy, little objective data is available regarding postoperative pain/ discomfort and use of analgesic medications after RARP. We sought to examine these parameters in a contemporary cohort. Patients and Methods: From 2011 to 2013, patients undergoing RARP were prospectively enrolled in a study to examine various pain parameters and carefully monitor opiate and other analgesic medication use while the patient recovered in the hospital. After discharge, the patients were asked to fill out a daily questionnaire regarding their pain parameters and self-report opiate usage. All questionnaires were based on the Wong-Baker FACES pain rating scale (0–10). Opiate dosages were converted to the approximate oral morphine sulfate equivalent dose (MSE). Results: A total of 60 patients, mean age 61 years, were enrolled in the study, underwent RARP, and completed follow-up questionnaires. None had a history of chronic narcotic use. Intraoperative opiate use was 94.1 mg MSE. There were 73.3% who received immediate postoperative ketorolac. After RARP, the main source of pain/discomfort was abdominal/incisional, followed by urethral catheter-related, penile, and bladder spasmrelated discomfort. Abdominal pain was generally moderate for most patients and decreased significantly after about 4 days. Penile and urethral catheter-related discomfort was mild throughout the study period. Opiate analgesic medication use quickly decreased as the subjective pain scores improved. Conclusions: After RARP, most patients experience mild/moderate abdominal discomfort, which improves steadily over several days. There is also a quick decline in the average opiate pain medication use that corresponds to the subjective improvement in pain symptoms. This information is useful for clinicians counseling patients on the pain associated with RARP and can serve as a reference to compare the convalescence associated with the other options for treatment of patients with localized prostate cancer. Introduction
P
rostate cancer can be managed via a variety of strategies, including extirpative and ablative surgery, radiation therapy, or even conservatively with active surveillance in select low-risk patients. Given the relative lack of clear data to suggest cancer-specific outcome differences in certain groups of patients with localized prostate cancer treated by any of the above-mentioned, patients and their physicians are left with a variety of secondary factors to consider when making the decision between available treatment options for their prostate cancer.1 For a patient who is confronted with this difficult decision, one of the most important factors weighing against prostatectomy vs the other treatment strategies is the potential postoperative pain and convalescence associated with surgery.
Within the broad category of extirpative surgery, there are a variety of approaches to radical prostatectomy, including open prostatectomy, which can be performed via a retropubic or perineal approach, laparoscopic prostatectomy, and most commonly now via robot-assisted radical prostatectomy (RARP). Since the advent of RARP in 1999, there has been rapid adoption of this approach that now represents about 80% of all prostatectomies performed in the United States.2 While proponents of RARP suggest a variety of advantages with the use of a robot for pelvic surgery, including reduced blood loss, reduced transfusion requirements, improved dexterity of instruments, one of the main advantages appears to be a decreased convalescence and improved postoperative pain.2–4 The majority of patients at high-volume centers are discharged on the first postoperative day.5
Department of Urology, Columbia University Medical Center, New York, New York.
544
PAIN AND ANALGESIC USE AFTER RARP
Despite how common the procedure has become, there is little objective data on postoperative convalescence after RARP. We performed a prospective study in a modern cohort of patients undergoing RARP to provide future patients and clinicians counseling patients on treatment options for prostate cancer with objective data on what they might reasonably expect after undergoing RARP. Patients and Methods
With Institutional Review Board approval from Columbia University Medical Center, patients from 2011 to 2012 with localized prostate cancer undergoing transperitoneal RARP were prospectively enrolled in a study to examine various pain parameters and carefully monitor opiate and other analgesic medication use while they recovered in the hospital and after discharge. Patients with an opiate allergy, chronically taking opiates, with a history of a pain syndrome, or with a history of drug or opiate abuse were excluded. Anesthesiologists were not involved in the study and did not deviate from their standard intraoperative or immediate postoperative analgesic protocols. No patients received a neuraxial block. RARP was performed by an experienced robotic surgeon (KKB) using the daVinci Si Surgical System (Intuitive Surgical, Sunnyvale, CA). The camera trocar was placed just to the left of the umbilicus and was extended at the conclusion of the procedure to allow for specimen extraction. This site was then closed with interrupted figureof-eight sutures. All skin incisions were infiltrated with 10 to 20 mL of 0.25% bupivacaine subcutaneously and closed using subcutaneous absorbable sutures. After the operation, physicians caring for the patient administered questionnaires related to the patient’s perceived pain from four anatomic sites: Abdominal or incisional pain, urethral catheter-related pain, penile pain, and bladder spasm-related pain. The questionnaires were based on the Wong-Baker FACES Pain Rating Scale, which is a visual analog scale on which patients record their perception of pain on a 0 to 10 point scale, with 0 representing ‘‘no hurt’’ and 10 representing ‘‘hurts worst.’’6 After the patients arrived in the postoperative recovery unit, the questionnaires were administered at 30 minutes, 90 minutes, 6 hours, 12 hours, 18 hours, and 24 hours postoperatively. All patients were discharged on postoperative day 1, and after discharge, the patients were asked to fill out the same questionnaire regarding their pain parameters on a daily basis for 9 days until they were seen for a follow-up appointment and catheter removal. All opiate and analgesic medication was carefully recorded via the electronic medication dispensation system at our institution, which does not allow for any medication to be administered to a patient without a nursing or anesthesia record of that medication. Medications that were recorded included all opiate analgesics, nonsteroidal anti-inflammatory medications (in the form of ketorolac 30 mg or 15 mg intravenous [IV]), and anticholinergic medications (in the form of oral [PO] oxybutynin 5 mg). Patients were all given the standard postoperative orders for RARPs at our institution, which included acetaminophen 325 mg PO, 1 tablet every 4 to 6 hours for a pain score 1 to 3 on a 10-point scale; acetaminophen/codeine 325 mg/30 mg PO, 1 tablet every 4 to 6 hours for a pain score 4 to 6 on a 10point scale; acetaminophen/codeine 325 mg/30 mg PO, 2
545
tablets every 4 to 6 hours for pain score 7 to 10 on a 10-point scale; and hydromorphone 1 mg IV every 3 hours for breakthrough pain. No patient received orders for standing opiate medication. Patients had a standing order for postoperative ketorolac IV (15 mg or 30 mg) every 6 to 8 hours if they had normal renal function and no operative contraindication. For those who experienced bothersome bladder spasms, anticholinergic medications were given on an as needed (PRN) basis in the form of oxybutynin 5 mg PO every 8 hours. On discharge, patients were typically given a prescription for acetaminophen/codeine 325 mg/30 mg PO, 1 to 2 tablets every 4 to 6 hours PRN. Once at home, in addition to filling out pain questionnaires, they were also asked to self-report opiate use on a daily basis. While the above analgesic medications and dosages represent our standards after RARP, the physicians taking care of the patient were at liberty to deviate from these standards if deemed necessary. All deviations from the standard protocol were recorded and reflected in the results of our analysis. To facilitate analysis, dosages of the various forms of opiate analgesics were converted to the approximate oral morphine sulfate equivalent dose (MSE).7 Because urologists are likely not to be familiar with MSE interpretation, we also converted from MSE to tablets of acetaminophen/ codeine in which 1 tablet of acetaminophen/codeine 325 mg/ 30 mg has the approximate equivalent opiate dosage of 4.5 mg MSE.7 Statistical analysis was performed using SPSS version 21.0 (IBM Corporation, Armonk, NY). Results
A total of 60 patients consented to the study and completed follow-up questionnaires. The mean age was 60.8 years (range 47–72 years). The mean prostate-specific antigen level was 6.2 ng/dL (range 0.9–24.0 ng/dL). The average body mass index was 27.8 (range 18.8–40.0). Four (6.7%) patients had a history of diabetes, 1 (1.7%) patient had a history of peripheral vascular disease. As per our exclusion criteria, no patients had a history of chronic opiate use, pain syndrome, or drug abuse. All patients underwent an uncomplicated RARP and were discharged on postoperative day 1. The mean total operative time was 186 minutes (range 150–210 min; Table 1). There were no readmissions during the study period. Immediately after RARP, the main source of pain/discomfort was abdominal, followed by catheter-related, penile, and bladder spasm-related discomfort. Figure 1 illustrates the severity and patterns of the different sources of pain after RARP. Patients reported a mean – standard deviation (SD) abdominal pain of 3.46 – 2.37 within the first 24 hours after surgery. This level of pain remained relatively constant for the first 4 days after discharge with a mean – SD score of 3.35 – 2.23. After the 4th postdischarge day, the level of pain began to decline steadily with a mean – SD score of 2.00 – 1.73 for postdischarge days 5 to 9 and reaching a nadir mean – SD pain score of 1.5 – 1.2 on the final 9th day of the study (Table 2). Patients reported the urethral catheter was associated with a mean – SD pain score of 1.27 – 1.63 within the initial 24 hours after surgery and rose slightly to a mean – SD of 2.36 – 2.34 (range 0–9) for up to 9 days after discharge. Similarly, penile pain was also reported within the initial 24 hours after surgery as low with mean – SD pain scores of
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Table 1. Patient Characteristics and Opiate Medication Use
Baseline clinical characteristics Age (years) BMI Diabetes PVD History of chronic narcotics use PSA (ng/mL) Operative time (min) Preoperative Gleason score 6 7 ‡8 Intraoperative medications Opiates (mean, mg MSE) Inpatient medications Periurethral lidocaine jelly use (%) Antimuscarinic use (%) Antimuscarinics (# doses of oxybutynin 5 mg) Opiates (mean, mg MSE) IV ketorolac use IV ketorolac (mean mg) Postdischarge medications Total opiates (mean, mg MSE)
Mean – SD
Range
60.8 27.8 4 (6.7%) 1 (1.7%) 0 (0%) 6.2 186
47–72 18.8–40.0
0.9–24.0 150–210
19 (31.7%) 34 (56.7%) 7 (11.7%) 94.1 – 39.6
7.5–215.0
7 (11.7%) 17 (28.3%) 0.83
0–10.0
41.2 – 45.5 44 (73.3%) 49.5 – 34.9
0–120.0
58.6 – 59.5
0–357.0
FIG. 1. Pain from various sources after robot-assisted radical prostatectomy.
0–182.0
SD = standard deviation; BMI = body mass index; PVD = peripheral vascular disease; PSA = prostate-specific antigen; MSE = morphine sulfate equivalent; IV = intravenous.
1.57 – 2.04 (range 0–10), and this rose while the patient recovered at home with mean pain scores from 1.93 (range 0–8, SD 2.33). Penile and catheter-related pain surpassed abdominal pain as the primary source of discomfort on postdischarge days 5 and 7, respectively. Bladder spasm-associated pain was initially low, with a mean – SD reported pain score of 0.84 – 2.28, but also rose slightly over the course of the postdischarge convalescence to a mean pain score of 1.86 – 2.63 and 1.58 – 2.49, for postdischarge days 1 to 4 and 5 to 9, respectively. The mean intraoperative opiate use was 94.1 mg MSE (range 7.5–215 mg, SD 39.6 mg). While recovering in the hospital for 24 hours, the mean inpatient opiate use was 41.2 mg MSE (range 0–182 mg, SD 45.5 mg). Forty-four (73.3%) patients received immediate postoperative ketorolac. Lidocaine jelly 2% was applied topically to the penile meatus for catheter-related discomfort in 7 (11.7%) patients. Seventeen (28.3%) patients received anticholinergic medications for pain associated with bladder spasms.
Once discharged from the hospital, the mean opiate use was 14.3 mg (range 0–45 mg, SD 9.1 mg) on the 1st postdischarge day and steadily decreased to 3.25 mg (range 0–45 mg, SD 7.7 mg) on the 9th day post-discharge. This corresponds to patients taking an average of 3.2 tablets of acetaminophen/codeine 325 mg/30 mg on the 1st discharge day and 0.7 tablets on the 9th discharge day (Fig. 2). The total opiate use after discharge from the hospital was 68.5 mg MSE (range 0–357 mg), which corresponds to 15.2 tablets of acetaminophen/codeine 325 mg/30 mg (range 0–79 tablets). Discussion
One of the proposed benefits of the adoption of the da Vinci Surgical System for RARP is decreased postoperative pain compared with open radical prostatectomy, but there is limited prospective data on what a patient undergoing RARP might reasonably expect in terms of pain and requirement of analgesic immediately after surgery and in the first week after recovering from the operation.8 Studies that indirectly attempt to address this question are typically in the context in trial of an analgesic technique vs placebo. In a study examining the effects of transversus abdominis plane block vs placebo on pain within 24 hours after open retropubic prostatectomy, the pain levels in the placebo arm were higher on average than in our group (4–6 on 10 point scale), but opiate requirements were generally similar at 45.5 mg MSE within
Table 2. Pain After Robot-Assisted Radical Prostatectomy (10-Point Pain Scale) Source of pain (Mean – SD) Time interval
Abdominal
Catheter-related
Penile
1st 24 hours postoperatively Days 1–4 after discharge Days 5–9 after discharge
3.46 – 2.37 3.35 – 2.23 2.00 – 1.73
1.27 – 1.63 2.25 – 2.03 2.46 – 2.59
1.57 – 2.04 1.88 – 2.21 1.98 – 2.44
SD = standard deviation.
Bladder spasm 0.84 – 2.28 1.86 – 2.63 1.58 – 2.49
PAIN AND ANALGESIC USE AFTER RARP
FIG. 2. Opiate analgesic use after robot-assisted radical prostatectomy. the first 24 hours after the operation.9 In another study in men undergoing RARP, patients were randomized to intravesical ropivacaine vs placebo and within the first 24 hours postoperatively, the authors reported the 20 patients in the placebo arm had similar mean pain scores and opiate requirements to those reported in our study.10 Webster and coworkers11 compared pain and opiate use after open prostatectomy and RARP and found lower mean pain scores (1.8 on 10-point scale) and opiate use (22.4 mg MSE) than in our cohort, but limited their analysis to the initial 24 hours after the operation and 2 weeks after the operation. Our study adds to the limited literature on this subject with increased sample size and longer careful follow-up, not just within the hospitalization period but beyond—once the patient is discharged home until the urethral catheter was removed. We feel this information is valuable in counseling patients about their treatment options after a diagnosis of localized prostate cancer, because the anxiety of potential pain associated with surgery is certainly a factor that weighs into a patient’s decision-making process. Our results indicate that the main source of discomfort within the first 5 days postRARP will most likely be from the abdomen and associated with the robotic arm port site incisions. The abdominal pain is relatively mild—on average rated 3 to 4 of 10 on a pain scale, and then decreases to below 2 of 10 within a week after the operation. While initially low, pain associated with the urinary catheter, penile pain, and pain associated with bladder spasms become a significant source of discomfort and even overtakes abdominal pain on the pain rating scale after about 5 to 6 days after the operation. Opiate analgesic use is predictably high during the short hospitalization, but declines precipitously as the patient recovers at home. On the first day at home, average opiate use is equivalent to about 3 to 4 tablets of acetaminophen/codeine 325 mg/30 mg. On average, after just 4 days of recovery, patients are taking fewer than 2 tablets of acetaminophen/codeine 325 mg/30 mg within a 24-hour cycle. Although this is a carefully coordinated and prospective study, there are several limitations that should be consid-
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ered. This study focused exclusively on robot-assisted prostatectomy performed by a single surgeon, which did not allow for direct comparison with open prostatectomy. Nonetheless, it is still relevant because the robotic approach has largely supplanted open surgery in the United States and we find that our patients are choosing between RARP and nonsurgical treatment options rather than considering options within extirpative surgery. Although we made a distinction between penile pain, catheter-related pain, and bladder spasm-related pain, it may be difficult for some patients to differentiate these different sources clearly in all cases. As is the case in any subjective questionnaire, the study participants have different pain thresholds, and this makes extrapolation difficult to an individual patient. Our study could have been improved if we had included questions related to how the pain after RARP interferes with the patient’s activities of daily living. Nonetheless, we think this study will give physicians an objective tool in counseling patients who are considering undergoing RARP but have reasonable concerns about what they may expect during their period of convalescence. Conclusions
RARP has been rapidly adopted as the primary surgical treatment of patients with localized prostate cancer for a variety of reasons, one of which is decreased pain postoperatively and a shorter convalescence period. Despite this, RARP is still abdominal surgery, and many patients have quite reasonable concerns about what to expect after surgery. Our study indicates that the abdominal pain is modest after the procedure and in most cases adequately controlled with a modest amount of opiate analgesics for the first 4 days after surgery. After 5 to 7 days, abdominal pain and opiate use declines significantly and is actually less bothersome than the discomfort associated with the penis and urethral catheter. This information should be useful in counseling patients on the merits of RARP vs other less invasive therapies for prostate cancer. Disclosure Statement
No competing financial interests exist. References
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7. Twycross RG, et al. Hospice and palliative care formulary USA. 2006, Nottingham: palliativedrugs.com. xxx, 467. 8. Tewari A, Srivsatava A, Menon M. Members of the VIP team. A prospective comparison of radical retropubic and robot-assisted prostatectomy: Experience in one institution. BJU Int 2003;92:205–210. 9. Elkassabany N, Ahmed M, Malkowicz SB, et al. Comparison between the analgesic efficacy of transversus abdominis plane (TAP) block and placebo in open retropubic radical prostatectomy: A prospective, randomized, doubleblinded study. J Clin Anesth 2013;25:459–465. 10. Fuller A, Vanderhaeghe L, Nott L, et al. Intravesical ropivacaine as a novel means of analgesia post-robot-assisted radical prostatectomy: A randomized, double-blind, placebocontrolled trial. J Endourol 2013;27:313–317. 11. Webster TM, Herrell SD, Chang SS, et al. Robotic assisted laparoscopic radical prostatectomy versus retropubic radical prostatectomy: A prospective assessment of postoperative pain. J Urol 2005;174:912–914.
WOLDU ET AL.
Address correspondence to: Solomon L. Woldu, MD Department of Urology Columbia University Medical Center Herbert Irving Pavilion, 11th Floor 161 Fort Washington Avenue New York, NY 10032 E-mail: [email protected]
Abbreviations Used IV ¼ intravenous RARP ¼ robot-assisted radical prostatectomy MSE ¼ morphine sulfate equivalent dose PO ¼ per os PRN ¼ pro re nata SD ¼ standard deviation
