Prostatectomy 2020

Prostatectomy-specific evidence

Data table: Paracetamol and NSAIDs/COX-2-selective inhibitors for pain management after prostatectomy

Arguments for…

• Open prostatectomy: One study showed reduced cumulative opioid consumption (24%) and decreased pain intensity with postoperative parecoxib vs placebo (Dirkmann 2015).
• From the previous review (Joshi 2015), in open prostatectomy:
  • Of three additional studies comparing NSAIDs/COX-2-selective inhibitors with placebo, two studies found a reduction in pain scores at rest and in opioid use (Bilgin 2011; Chelly 2011); one study found no significant difference (Huang 2001).
  • Another study found a reduction in pain scores at rest with lornoxicam vs paracetamol (Mazaris 2008).

Arguments against…

• Robot-assisted prostatectomy: One study found no difference in opioid use and pain scores between paracetamol and placebo, but the length of hospital stay was reduced in the paracetamol group (Wang 2019).
• From the previous review (Joshi 2015), in open prostatectomy:
  • One study found no significant difference in pain scores between aspirin and tiaprofenic acid (Ormiston 1981).

PROSPECT Recommendations

• Systemic analgesia should include paracetamol and selective or non-selective NSAIDs administered pre-operatively or intra-operatively and continued postoperatively.
  • NSAIDs and COX-2-selective inhibitors lowered postoperative pain scores and opioid use (Dirkmann 2015; Mazaris 2008; Bilgin 2011; Chelly 2011).
  • Paracetamol is recommended despite limited procedure-specific evidence, based on previous recommendations (Joshi 2015).

Prostatectomy-specific evidence

Data table: Dexmedetomidine for pain management after prostatectomy

Arguments against…

• Open prostatectomy: One study found no difference in pain scores or analgesic use between an intra-operative infusion of dexmedetomidine (0.3 μg/kg/h) and placebo (Ogrič 2017). Baseline analgesia consisted of paracetamol and piritramide PCA.

PROSPECT Recommendations

• Dexmedetomidine is not recommended due to lack of procedure-specific evidence.

Prostatectomy-specific evidence

Data table: Gabapentinoids for pain management after prostatectomy

Arguments for…

• Open prostatectomy: One study found that gabapentin 2 h before surgery was associated with lower VAS pain scores, comparable tramadol consumption, and fewer patients requiring rescue analgesia vs placebo, without reported adverse effects (Deniz 2012). All patients received diclofenac and paracetamol.

PROSPECT Recommendations

• Gabapentin is not recommended due to limited procedure-specific evidence and concern about side effects.

Prostatectomy-specific evidence

Data table: IV lidocaine for pain management after prostatectomy

Arguments for…

• Open prostatectomy: One study found that lidocaine (pre-operative IV bolus, followed by intra-operative continuous infusion and 24-h postoperative subcutaneous infusion) was associated with lower VAS pain scores at rest during the first 24 h and lower morphine consumption at 24 h vs saline placebo (Weinberg 2016). Baseline analgesia was paracetamol, ketorolac and morphine PCA.
• From the previous review (Joshi 2015), in open prostatectomy:
  • One study found a reduction in pain scores with lidocaine infusion vs placebo (Groudine 1998).

Arguments against…

• From the previous review (Joshi 2015), in laparoscopic prostatectomy:
  • One study found no difference in pain scores but a reduction in opioid use with lidocaine infusion vs placebo (Lauwick 2009).

PROSPECT Recommendations

• Continuous IV lidocaine is recommended during open surgery.
  • Its use contraindicates the simultaneous use of infiltration with local anaesthetics (Foo 2021).
  • The duration of lidocaine infusion should be limited to the intra-operative and immediate postoperative periods for safety reasons.
  • Continuous IV lidocaine reduced postoperative pain scores during open surgery (Groudine 1998; Weinberg 2016).

Prostatectomy-specific evidence

Data table: TAP block for pain management after prostatectomy

Arguments for…

• Robotic surgery: Three studies evaluated TAP block, and all found a reduction in pain scores compared with placebo/control (Dal Moro 2019; Cacciamani 2019; Taninishi 2020). None of these studies reported the TAP block effect duration.
  • One study compared bilateral TAP block (200 ml bupivacaine 2.5 mg/ml) performed postoperatively vs placebo (Dal Moro 2019). Results showed significantly lower intra-operative opioid use in the TAP block group, together with a lower pain score and postoperative analgesic (tramadol and ketoprofen) requirements.
  • Postoperative TAP block combined with wound infiltration was associated with lower pain scores and tramadol requirements compared with wound infiltration alone (Cacciamani 2019).
  • A third study found a significant difference in pain scores but comparable postoperative morphine consumption when comparing bilateral TAP block with placebo (Taninishi 2020).

Arguments against…

• Open prostatectomy: Of three studies evaluating bilateral TAP block vs placebo/control (Elkassabany 2013; Skjelsager 2013; Maquoi 2016), two found no significant difference in pain scores or opioid requirements (Skjelsager 2013; Maquoi 2016). None of these studies reported the TAP block effect duration.
  • One study compared TAP block (20 ml bupivacaine 5 mg/ml) after induction of general anaesthesia vs control sham block (20 ml saline) and found VAS pain scores to be lower during only 6 h in the TAP block group (Elkassabany 2013). Baseline analgesia was provided by IV morphine PCA in both groups, after a ketorolac administration at the end of surgery.
  • Another study compared TAP block, wound infiltration and placebo at the end of surgery, finding no difference in pain scores or morphine consumption (Skjelsager 2013). Pre-operatively, all patients received oral gabapentin, ibuprofen and paracetamol; postoperatively, patients received oral paracetamol and ibuprofen and IV morphine PCA. The first group received bilateral TAP block (20 ml ropivacaine 7.5 mg/ml on each side) and a placebo wound infiltration; the second group had a surgical wound infiltration with 40 ml ropivacaine 7.5 mg/ml and a placebo bilateral TAP block; the third group had a placebo bilateral TAP block and a placebo wound infiltration.
  • A third study found comparable VAS pain scores and opioid requirements with TAP block (levobupivacaine) at the end of surgery plus IV saline vs IV lidocaine (1.5 mg/kg bolus before induction then continuous infusion 2 mg/kg/h until the end of surgery) vs placebo (saline) TAP block and IV infusion (Maquoi 2016). All patients received paracetamol during surgery and piritramide in the recovery room, then paracetamol in the wards and piritramide PCA as rescue.

PROSPECT Recommendations

• TAP block is recommended as the first choice for laparoscopic/robotic radical prostatectomy.
  • Bilateral TAP block performed at the end of surgery lowered pain scores in robot-assisted procedures (Dal Moro 2019; Cacciamani 2019; Taninishi 2020), but results were conflicting for open procedures.
• TAP block is not recommended for open prostatectomy procedures.

Prostatectomy-specific evidence

Data table: Local wound infiltration for pain management after prostatectomy

Arguments for…

• Open prostatectomy: One study used a subfascial catheter with a bolus of 2.5 mg/ml bupivacaine followed by an infusion of 5 ml/h bupivacaine or saline, finding a higher morphine PCA demand in the placebo group during the first 2 h postoperatively, but no difference in the total postoperative morphine use (Kristensen 2013).
• From the previous review (Joshi 2015), in open prostatectomy:
  • One study found reduced pain scores and analgesic use with wound infiltration (0.5% bupivacaine during surgical closure) and IM 75 mg diclofenac vs placebo (Bilgin 2011).
  • One study showed a reduction in pain scores on movement and in supplementary analgesic use with wound infiltration with magnesium vs placebo (under remifentanil-based anaesthesia) (Lee 2011).
  • Another study found no difference in pain scores but a reduction in supplementary analgesic use when comparing wound infiltration of ropivacaine plus magnesium vs infiltration of ropivacaine plus IV magnesium (Tauzin-Fin 2009).
  • A further study found no significant difference between subfascial bupivacaine and placebo in terms of pain scores at rest and on movement, and supplementary analgesic use (Wu 2005).

PROSPECT Recommendations

• Local wound infiltration should be used routinely for open surgery before other regional analgesia blocks, in the absence of IV lidocaine use.
  • Local wound infiltration showed positive results in open surgery (Bilgin 2011; Kristensen 2013; Tauzin-Fin 2009; Lee 2011).
• Magnesium sulphate by wound infiltration or intravenous administration is not recommended due to limited procedure-specific evidence.

Prostatectomy-specific evidence

Data table: Intravesical local anaesthetics for pain management after prostatectomy

Arguments against…

• Robot-assisted radical prostatectomy: One study compared intravesical instillation of 20 ml ropivacaine 10 mg/ml during 1 h vs placebo, finding no effect on VAS pain scores and morphine use. However, there was a significant reduction in the cumulative dose of ketorolac (Fuller 2013).

PROSPECT Recommendations

• Intravesical local anaesthetics are not recommended due to lack of procedure-specific evidence.

Prostatectomy-specific evidence

Data table: Intrathecal opioid for pain management after prostatectomy

Arguments for…

• Robot-assisted prostatectomy: Two studies found a reduction in pain scores and opioid consumption with intrathecal opioid vs control (Bae 2017; Koning 2019). Neither study documented the duration of the effect of intrathecal morphine.
  • One study found lower pain scores and postoperative morphine consumption with spinal morphine 300 μg and IV morphine PCA as rescue compared with IV morphine PCA alone (Bae 2017). There was no difference in side effects.
  • Another study reported lower pain scores and postoperative opioid consumption with intrathecal injection of bupivacaine 12.5 mg and morphine 300 μg compared with sham intrathecal injection before general anaesthesia (Koning 2019). Patients received paracetamol, metamidazol and morphine PCA as baseline analgesia.
• Open prostatectomy: One study found a reduction in pain scores and a lower use of tramadol and rescue analgesia with intrathecal morphine 200 μg compared with no intrathecal morphine (Nuri Deniz 2013). Basic analgesia was paracetamol, diclofenac and baseline analgesia of tramadol PCA. Intrathecal morphine was not associated with a significant increase in side effects. The study did not document the duration of the effect of intrathecal morphine.
• From the previous review (Joshi 2015), in open prostatectomy:
  • Two further studies showed a reduction in pain scores and opioid consumption with the use of intrathecal morphine plus clonidine vs placebo or control (Andrieu 2009; Brown 2004).

PROSPECT Recommendations

• Intrathecal opioid is not recommended due to the risk of adverse effects.

Prostatectomy-specific evidence

Data table: Epidural analgesia for pain management after prostatectomy

Arguments for…

• Laparoscopic prostatectomy: One study compared PCEA ropivacaine and morphine (settings controlled to maintain vital signs within 20% of basal levels with a 30-min lockout) vs IV PCA with nefopam 1 mg and oxycodone 1 mg (Hwang 2018). Pain scores and cumulative consumption of local anaesthetic were lower in the PCEA group.
• Open prostatectomy: Two studies found lower pain scores with epidural analgesia compared with IV opioid PCA, without mention of any basic analgesia.
  • In one study, thoracic epidural analgesia (bolus injection after insertion of the epidural catheter, then continuous administration of bupivacaine) and general anaesthesia was associated with lower pain scores on a numerical scale, on the first postoperative day, compared with general anaesthesia alone (Baumunk 2014).
  • In another study, epidural analgesia was associated with lower pain scores on coughing, during 24 h after surgery, and significantly lower postoperative morphine consumption (Fant 2013).
• From the previous review (Joshi 2015), in open prostatectomy:
  • Two studies comparing epidural analgesia vs systemic analgesia found a reduction in pain scores, at rest (Allaire 1992; Gupta 2006) and on coughing (Gupta 2006). Allaire 1992 compared epidural fentanyl with IV morphine; Gupta 2006 compared epidural ropivacaine, fentanyl and adrenaline plus placebo via IV PCA vs epidural placebo and morphine via IV PCA.
  • A further two studies found no significant difference in pain scores (Hohwü 2006; Liu 1995). Hohwü 2006 compared epidural ropivacaine vs bupivacaine infiltration plus oral oxycodone; Liu 1995 compared epidural hydromorphone vs hydromorphone via IV PCA.

PROSPECT Recommendations

• Epidural analgesia is not recommended due to the unfavourable benefit/risk balance.

Prostatectomy-specific evidence

Data table:Epidural-caudal block for pain management after prostatectomy

Arguments against…

• Robot-assisted prostatectomy: One study found no decrease in pain scores and opioid use with caudal block vs standard analgesia (Chen 2018).

PROSPECT Recommendations

• Epidural-caudal block is not recommended due to lack of procedure-specific evidence.

Prostatectomy-specific evidence

Data table: Rectus sheath block for pain management after prostatectomy

Arguments against…

• Open radical prostatectomy: Ultrasound-guided bilateral rectus sheath block with 20 ml bupivacaine 5 mg/ml was associated with a lower pain score and opioid use, during the first day, compared with placebo (Ibrahim 2018). Both groups had systemic analgesia with paracetamol and ketorolac, with morphine as rescue.

PROSPECT Recommendations

• Rectus sheath block is not recommended due to lack of procedure-specific evidence.

Prostatectomy-specific evidence

Data table: Penile block for pain management after prostatectomy

Arguments against…

• Open prostatectomy: One study compared dorsal penile nerve block with bupivacaine vs saline for urethral catheter-related pain, and reported a lower abdominal pain score at 6 h postoperatively but no difference at other time points (Weinberg 2014).

PROSPECT Recommendations

• Penile block is not recommended due to lack of procedure-specific evidence.

Prostatectomy-specific evidence

Data table: Robot/laparoscopic vs open surgery for pain management after prostatectomy

Arguments for…

• One RCT compared robot-assisted vs open prostatectomy, and reported that the robot-assisted group reported significantly less pain during normal activities in the early postoperative period until one week postoperatively (Yaxley 2016). There was no difference in postoperative analgesic consumption.
• A meta-analysis (in which the Yaxley 2016 study was included) found that studies evaluating pain after robotic surgery, vs open surgery, documented lower postoperative pain after robotic surgery that also contributed to improved patient comfort and a better recovery (Ilic 2017).

PROSPECT Recommendations

• PROSPECT makes no specific recommendations regarding the use of robot-assisted/laparoscopic prostatectomy vs open prostatectomy. However, studies confirm that robot-assisted surgery is less painful than open prostatectomy.

Prostatectomy-specific evidence

Data table: Valveless trocar for pain management after prostatectomy

Arguments for…

• Robot-assisted prostatectomy: One study evaluated a valveless trocar system and found lower VAS pain scores compared with standard trocars (Shahait 2019).

PROSPECT Recommendations

• Valveless trocar is not recommended due to limited procedure-specific evidence.

Prostatectomy-specific evidence

Data table: CO₂ warmed and humidified for pain management after prostatectomy

Arguments against…

• Robot-assisted prostatectomy: One study compared warmed and humidified CO₂ insufflation with standard CO₂ insufflation, finding no difference in pain scores (Oderda 2019). Both groups also received a hot air warming blanket.

PROSPECT Recommendations

• CO₂ warmed and humidified is not recommended due to lack of procedure-specific evidence.

Prostatectomy-specific evidence

Data table: Incision type for pain management after prostatectomy

• Open prostatectomy: One study found no difference in pain scores or opioid use between transverse or longitudinal incision techniques (Kava 2010).

PROSPECT Recommendations

• PROSPECT makes no specific recommendation for the choice between transverse and longitudinal incision due to lack of procedure-specific evidence.

Prostatectomy-specific evidence

Data table: Catheter techniques for pain management after prostatectomy

Arguments for…

• Robot-assisted prostatectomy:
  • One study compared suprapubic catheters vs urinary catheters, and found that suprapubic catheters were less bothersome for patients (Martinschek 2016). However, pain scores did not differ between the two groups except for postoperative days 5 and 6, when the suprapubic catheter group reported lower catheter-related pain scores without any difference in overall pain scores.
  • A second study found no difference in pain scores or side effects between urethral catheters and suprapubic catheters (Prasad 2014).
  • Two meta-analyses compared transurethral vs suprapubic catheters, with different conclusions (Li Z. 2019; Li M. 2019). Li Z. 2019 found less postoperative pain in the suprapubic catheter group; Li M. 2019 found no conclusive difference.
  • A further study found that early catheter removal on day 3, compared with standard removal on day 5, was associated with a shorter length of hospital stay, together with less discomfort and pain on discharge, without any difference in the incidence of complications (Lista 2018).

PROSPECT Recommendations

• PROSPECT makes no specific recommendation for the choice of catheter type due to lack of procedure-specific evidence.
• Early catheter removal is not recommended due to limited procedure-specific evidence.