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Prostatectomy 2020

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Summary Recommendations

PROSPECT provides clinicians with supporting arguments for and against the use of various interventions in postoperative pain based on published evidence and expert opinion. Clinicians must make judgements based upon the clinical circumstances and local regulations. At all times, local prescribing information for the drugs referred to must be consulted.

Pain remains an important issue after radical prostatectomy, resulting in discomfort and sometimes prolonged hospital stay (Tan 2015). Adequate pain management is needed to optimise postoperative recovery (Joshi 2014).

Patients undergoing open radical prostatectomy typically experience moderate dynamic pain in the immediate postoperative days (d’Alonzo 2009). Robot-assisted and laparoscopic surgery is less painful than open prostatectomy, although trocar ports may be a source of parietal pain after robot surgery (d’Alonzo 2009; Woldu 2014). Postoperative analgesic protocols should reflect these different pain profiles and the specific evidence identified in the literature.

The aim of this review was to update the recommendations for optimal pain management after open and laparoscopic or robotic prostatectomy.

PROSPECT recommendations for radical prostatectomy, based on a systematic literature review, were initially published in 2015 (Joshi 2015), which updated the literature and recommendations made on the website in 2012 (Archive: Radical prostatectomy 2012). However, several new analgesic regimens, particularly regional analgesic techniques, have since been introduced and robot surgery has been developed on a larger scale, so an update to the systematic review was warranted.

The recommendations for the current review have been built on those of the previous review, supported by additional information from the more recent studies.

The unique PROSPECT methodology is available at https://esraeurope.org/prospect-methodology/.

Recommended: Pre- and intra-operative interventions

  • ‘Pre-operative’ refers to interventions applied before surgical incision and ‘intra-operative’ refers to interventions applied after incision and before wound closure
  • Analgesics should be administered at the appropriate time (pre- or intra-operatively) to provide sufficient analgesia in the early recovery period
Paracetamol, NSAIDs, COX-2-selective inhibitors Systemic analgesia should include paracetamol and selective or non-selective NSAIDs administered preoperatively or intraoperatively and continued postoperatively
Continuous IV lidocaine 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 intraoperative and immediate postoperative periods for safety reasons
  • Continuous IV lidocaine reduced postoperative pain scores during open surgery (Groudine 1998; Weinberg 2016)
Local wound infiltration Local wound infiltration should be used routinely for open surgery before other regional analgesia blocks, in the absence of IV lidocaine use
TAP block TAP block is recommended as the first choice for laparoscopic/robotic radical prostatectomy

COX, cyclooxygenase; IV, intravenous; NSAIDs, non-steroidal anti-inflammatory drugs; TAP, transversus abdominis plane.

Recommended: Postoperative interventions

  • ‘Postoperative’ refers to interventions applied at or after wound closure
  • Analgesics should be administered at the appropriate time (pre- or intra-operatively) to provide sufficient analgesia in the early recovery period
Paracetamol, NSAIDs, COX-2-selective inhibitors Systemic analgesia should include paracetamol and selective or non-selective NSAIDs administered preoperatively or intraoperatively and continued postoperatively
Opioid Opioids should be used as rescue analgesics in the postoperative period

COX, cyclooxygenase; NSAIDs, non-steroidal anti-inflammatory drugs.

Interventions that are NOT recommended

Analgesic interventions that are not recommended for pain management in patients undergoing radical prostatectomy.

Intervention

Reason for not recommending
Gabapentin Limited procedure-specific evidence/side effects
Dexmedetomidine Lack of procedure-specific evidence
Intravesical local anaesthetics Lack of procedure-specific evidence
Intrathecal opioid Not recommended due to the risk of adverse effects
Epidural Unfavourable benefit/risk balance
Epidural-caudal block Lack of procedure-specific evidence
TAP block Not recommended for open
Rectus sheath block Lack of procedure-specific evidence
Electro-acupuncture Limited procedure-specific evidence
Magnesium sulphate wound infiltration/intravenous Limited procedure-specific evidence
Penile block Lack of procedure-specific evidence
Valveless trocar Limited procedure-specific evidence
Transverse vs longitudinal incision Lack of procedure-specific evidence
Intravesical installation ropivacaine Lack of procedure-specific evidence
Suprapubic vs urethral catheter Lack of procedure-specific evidence
Urethral catheter vs suprapubic and urethral catheter Lack of procedure-specific evidence
Early catheter removal Limited procedure-specific evidence
CO2 warmed and humidified Lack of procedure-specific evidence
Anaesthetic techniques No specific recommendations for anaesthetic technique

TAP, transversus abdominis plane.

 

Overall recommendations for peri-operative pain management in patients undergoing radical prostatectomy
Paracetamol Recommended despite limited procedure-specific evidence (Grade B)
Systemic lidocaine Intraoperative continuous intravenous infusion of lidocaine is recommended for open surgery (Grade B)
NSAIDs or COX-2-selective inhibitors Recommended provided there are no contra-indications (Grade A)
TAP block Recommended for laparoscopic/robotic procedures (Grade A)
Wound infiltration Recommended for open surgery (Grade B)

COX, cyclooxygenase; NSAID, non-steroidal anti-inflammatory drug; TAP, transversus abdominis plane.