An Analysis of Post-Operative Pain and Narcotic Use Following Robotic Assisted Laparoscopic Prostatectomy for Same Day Discharge - Beyond the Abstract

The COVID-19 pandemic sparked numerous shifts in previously held medical dogma. At its peak, many hospitals stopped performing elective procedures requiring a postoperative inpatient stay due to the increased demand for inpatient beds and staffing shortages. This caused many Urologists to re-evaluate what procedures could be safely performed on an outpatient basis.

Robotic-assisted laparoscopic prostatectomy is one of the most common Urologic procedures after which patients have traditionally been admitted. Fortunately, most patients are discharged on postoperative day one after an uncomplicated hospital course. There has been a focus on the management of radical prostatectomy patients and the feasibility of same-day discharge. There is currently a lack of data identifying which post-prostatectomy patients may tolerate same day discharge. While there are many factors contributing to this, this study sought to concentrate on postoperative pain control.

We retrospectively analyzed postoperative pain scores from nursing reports and narcotic usage for 150 patients undergoing robotic-assisted laparoscopic prostatectomy at our institution between March 2020 and January 2021. We assessed both variables in a two-hour post-operative period, to simulate the time that would be spent in the Postoperative Anesthesia Care Unit, and the entire duration of their stay, to simulate what they may experience if discharged home. We then tried to correlate postoperative pain and narcotic usage at these different time points with patient factors (e.g., age, body mass index (BMI), prostate size, tumor pathology) and intraoperative factors (e.g., operative time, total regional analgesia dose, and pneumoperitoneum pressure).

We discovered that average pain scores greater than three or any amount of narcotics given at two hours postoperatively were significantly associated with continued postoperative pain averaged over the remainder of admission (p < 0.001). Narcotic usage postoperatively was associated with lower BMI and longer operative times. However, there were no other patient factors or intraoperative factors that correlated with an average pain score greater than three or any amount of postoperative narcotic medication given. Interestingly, this includes total regional analgesia dose and pneumoperitoneum pressure, which traditionally have been thought to correlate with postoperative pain.

This study demonstrates that immediate postoperative pain control after robotic-assisted laparoscopic prostatectomy correlates with sustained postoperative pain control. If this were translated into a same-day discharge protocol, patients would stay in the Postoperative Anesthesia Care Unit for two hours with regular monitoring of pain scores by nursing staff. If average pain score is less than three and if the patient did not require any narcotics during that time, he could be considered safe for discharge from a pain perspective. With this manuscript, we hope to lay the groundwork to develop objective criteria for safe same-day discharge protocols after robotic-assisted laparoscopic prostatectomy.

Written by: Joshua Palka & Shilpa Argade, Division of Urologic Surgery, Washington University School of Medicine, St. Louis, MO

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