Comparison of analgesic efficacy between rectus sheath blockade, intrathecal morphine with bupivacaine, and intravenous patient-controlled analgesia in patients undergoing robot-assisted laparoscopic prostatectomy: a prospective, observational clinical study

Abstract

Background We explored the analgesic outcomes on postoperative day (POD) 1 in patients undergoing robot-assisted laparoscopic prostatectomy (RALP) who received intravenous patient-controlled analgesia (IV-PCA), rectus sheath bupivacaine block (RSB), or intrathecal morphine with bupivacaine block (ITMB). Methods This was a prospective, observational clinical trial. Patients were divided into three groups: IV-PCA (n = 30), RSB (n = 30), and ITMB (n = 30). Peak pain scores at rest and with coughing, cumulative IV-PCA drug consumption, the need for IV rescue opioids, and Quality of Recovery-15 (QoR-15) questionnaire scores collected on POD 1 were compared among the groups. Results The preoperative and intraoperative findings were comparable among the groups; the ITMB group required the least remifentanil of all groups. During POD 1, the ITMB group reported lower levels of pain at rest and with coughing, compared with the other two groups. During POD 1, incidences of severe pain at rest (10.0% vs. 23.3% vs. 40.0%) and with coughing (16.7% vs. 36.7% vs. 66.7%) were the lowest in the ITMB group compared with the RSB and IV-PCA groups, respectively. After adjustment for age, body mass index, diabetes mellitus, hypertension, and intraoperative remifentanil infusion, severe pain at rest was 0.167-fold less common in the ITMB group than in the IV-PCA group, while pain with coughing was 0.1-fold lower in the ITMB group and 0.306-fold lower in the RSB group, compared with the IV-PCA group. The ITMB group required lower cumulative IV-PCA drug infusions and less IV rescue opioids, while exhibiting a better QoR-15 global score, compared with the other two groups. Complications (nausea and pruritus) were significantly more common in the ITMB group than in the other two groups; however, we noted no ITMB- or RSB-related anesthetic complications (respiratory depression, post-dural headache, nerve injury, or puncture site hematoma or infection), and all patients were assessed as Clavien-Dindo grade I or II during the hospital stay. Conclusion Although ITMB induced complications of nausea and pruritus, this analgesic technique provided appropriate pain relief that enhanced patient perception related to early postoperative recovery. Trial registration Clinical Research Information Service, Republic of Korea, (approval number: KCT0005040) on May 20, 2020

Impact of analgesic techniques on early quality of recovery after prostatectomy: A 3‐arm, randomized trial

“…Numerous RCTs showed that multimodal concepts reduce the need for systemic analgesia after ORP or RARP (Andrieu et al, 2009; Brown et al, 2004; Ripolles et al, 2015; Shim et al, 2020; Wu et al, 2005). However, the literature is scarce investigating their impact on quality of recovery as measured by the QoR‐15 questionnaire.…”

Comment on “Comparison of analgesic efficacy between rectus sheath blockade, intrathecal morphine with bupivacaine, and intravenous patient-controlled analgesia in patients undergoing robot-assisted laparoscopic prostatectomy: a prospective, observational clinical study”

“…We read with great interest the article “Comparison of analgesic efficacy between rectus sheath blockade, intrathecal morphine with bupivacaine, and intravenous patient-controlled analgesia in patients undergoing robot-assisted laparoscopic prostatectomy: a prospective, observational clinical study” by Shim et al [ 1 ] Yet we think that there are relevant methodological issues and therefore we raise concerns about the potential for generalization of the results for other centers.…”

Letter to the editor: Reply

“…We appreciate the valuable comments on our submitted article [ 1 ] provided by Löffel et al We compared the analgesic outcomes on postoperative day (POD) 1 in patients undergoing robot-assisted laparoscopic prostatectomy (RALP) who received a rectus sheath block (RSB) or an intrathecal morphine and bupivacaine block (ITMB) with those of patients who received intravenous patient-controlled analgesia (IV-PCA) alone. Below are our responses to each comment.…”

“…The patients undergoing prostate surgery in our study, including RALP, were elderly (median [IQR] age = 65 [62–71] years) [ 1 ]. Surgeons and physicians typically have clinical concerns regarding postoperative desaturation due to atelectasis or residual effects of analgesic or anesthetic drugs, outside of our trial.…”

“…Therefore, a minimum sample size of 27 patients/group was required to afford an α value of 0.05 and a power of 0.8. We recruited 30 patients for each group assuming a dropout rate of 10% (these are demonstrated in the Statistical analysis section of our article) [ 1 ].…”