Presentation Authors: Kyrollis Attalla*, François Audenet, Morgane Giordano, John Pfail, Marc Lubin, Nikhil Waingankar, Daniel Gainsburg, Ketan Badani, Alan Sim, John Sfakianos, New York, NY
Introduction: Drug overdose have become the leading cause of death in Americans under 50 years old, and the use of opioid pain relievers accounts for approximately half of opioid-overdose deaths. Patients undergoing robot-assisted radical cystectomy (RARC) remain exposed to the potentially adverse effects of narcotic use. We describe the feasibility and outcomes of the prospective implementation of a non-opioid (NOP) protocol for patients undergoing RARC.
Methods: We prospectively included 52 consecutive patients undergoing RARC for bladder cancer at our institution. Patients received a multimodal pain management protocol including a combination of non-opioid pain medications and regional anesthesia. Patients received acetaminophen, gabapentin, and celecoxib per os immediately perioperatively. General anesthesia was induced using ketamine and propofol. Intraoperatively, patients received propofol, ketamine and dexmedetomidine. Regional block was performed prior to incision, with quadratus lumborum block or transversus abdominis/rectus sheath, using 0.25% bupivicaine. Intraoperative analgesic medications included acetaminophen IV every 6 hours from preoperative oral dose and ketorolac at the end of the procedure. Postoperative pain was managed with IV acetaminophen, ketorolac every 6 hours and gabapentin every 8 hours. For comparison, we retrospectively included 41 consecutive patients who received the same procedure before implementation of the NOP protocol.
Results: There was no significant difference in demographic and perioperative characteristics between the two groups. Patients included in the NOP protocol received a lower dose of postoperative morphine milligram equivalents (2.5 [IQR: 0-23] versus 44 [14.5-128], p < 0.001), with no difference in pain scores. In the NOP protocol, the median time to regular diet was significantly shorter (4 days [IQR: 3-5] versus 5 days [IQR: 4-8], p=0.002) and the length of stay was 2 days shorter compared to the control group (5 days [IQR: 4-7] versus 7 days [IQR: 6-11], p < 0.001). When evaluating the direct costs within 30 days after initial surgery, the NOP protocol was associated with an 8.6% reduction as compared to the control group (p=0.032). In multivariate analysis, the receipt of the NOP protocol was a significant predictor of a length of stay < 7 days after RARC (OR: 12.09; 95% CI: 1.70-140; p=0.023).
Conclusions: The prospective implementation of a NOP protocol for patients undergoing RARC is feasible, allowing for minimal narcotic usage, improved length of stay, and reduced costs.