Skip to main content
Download PDF
  • Research article
  • Open access
  • Published:

Optimal pain management for radical prostatectomy surgery: what is the evidence?

BMC Anesthesiology volume 15, Article number: 159 (2015) Cite this article

Abstract

Background

Increase in the diagnosis of prostate cancer has increased the incidence of radical prostatectomy. However, the literature assessing pain therapy for this procedure has not been systematically evaluated. Thus, optimal pain therapy for patients undergoing radical prostatectomy remains controversial.

Methods

Medline, Embase, and Cochrane Central Register of Controlled Trials were searched for studies assessing the effects of analgesic and anesthetic interventions on pain after radical prostatectomy. All searches were conducted in October 2012 and updated in June 2015.

Results

Most treatments studied improved pain relief and/or reduced opioid requirements. However, there were significant differences in the study designs and the variables evaluated, precluding quantitative analysis and consensus recommendations.

Conclusions

This systematic review reveals that there is a lack of evidence to develop an optimal pain management protocol in patients undergoing radical prostatectomy. Most studies assessed unimodal analgesic approaches rather than a multimodal technique. There is a need for more procedure-specific studies comparing pain and analgesic requirements for open and minimally invasive surgical procedures. Finally, while we wait for appropriate procedure specific evidence from publication of adequate studies assessing optimal pain management after radical prostatectomy, we propose a basic analgesic guideline.

Peer Review reports

Background

Prostate cancer is the most common cancer in men, with more than 240.000 patients newly diagnosed per year in the United States alone [1]. Radical prostatectomy remains one of the key techniques to treat prostate cancer [2], and the incidence of surgery has risen with improved prostate-specific antigen screening programmes [3, 4].

Optimal pain management is known to influence postoperative recovery [5], but patients undergoing open radical prostatectomy typically experience moderate dynamic pain in the immediate postoperative days [6]. Robot-assisted and laparoscopic surgery may be associated with decreased pain levels as opposed to open surgery [6], but even here, abdominal and incisional pain are prominent sources of moderate dynamic pain scores [7, 8].

The literature assessing the efficacy of various analgesic drugs and techniques in patients undergoing radical prostatectomy has not been systematically evaluated. Consequently, optimal pain therapy for patients undergoing radical prostatectomy remains to be defined.

The aim of the present systematic review is to evaluate the available literature on the management of pain after radical prostatectomy. Postoperative pain outcomes (e.g., pain scores and supplemental analgesic requirements) are the primary focus, but other recovery outcomes, including adverse effects, are also assessed where reported, and the limitations of the data are reviewed. This systematic review will also be used to determine the knowledge gaps, which will guide future research. In addition, this review can serve as a starting point for developing recommendations for clinical decision-making in the management of pain after radical prostatectomy surgery.

Methods

Systematic literature search

Medline, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies comparing analgesic and anesthetic interventions in patients undergoing radical prostatectomy according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines [9]. All searches were conducted in October 2012 without restriction to the publication date by using a combination of text words and data-base specific controlled terms related to prostatectomy, analgesia and pain assessment. We also manually retrieved publications referred in studies identified by our preceding search. The search was updated in June 2015.

Study inclusion and selection

The selection process was performed in a two-step procedure. First, two reviewers selected studies independently by screening the titles and abstracts according to predefined inclusion criteria: randomized controlled trials (RCTs) published as full-text in English assessing analgesic, anesthetic and surgical techniques affecting postoperative pain in patients undergoing radical prostatectomy. In studies with mixed surgical procedures there had to be a defined prostatectomy subgroup. After retrieving potential relevant studies, full-texts were checked against the inclusion criteria once again. Any disagreements were resolved by consensus. In the case of insolvable discrepancies, a third reviewer was involved in the discussion.

Quality assessment and outcome analysis

For the critical appraisal of included studies we used the Cochrane Collaboration’s tool for assessing the risk of bias [10]. The data extraction tables summarize pain scores, supplementary analgesic use and time to first analgesic requirement. It was assumed that the postoperative pain scores were assessed at rest, unless otherwise specified in the study report. Studies were stratified according to the regimen (analgesic, anesthetic and operative), mode of delivery (systematic or local) and class of agent. The assessment of the risk of bias and data extraction were conducted by one author and checked by a second author. Any disagreements were resolved by discussion or by consultation of a third reviewer. Quantitative meta-analyses were not performed, owing to the limited number of included studies with homogenous designs reporting similar outcome measures.

Results

Study selection process

In the search until October 2012, 38 studies met the inclusion criteria (Fig. 1), of which, an open approach was performed in 34 studies [11–43], a laparoscopic approach was performed in 1 study [44], and a robotic-assisted laparoscopic approach was performed in 3 studies [45–47]. Due to insufficient reporting the surgical approach was unclear in one study [48].

Fig. 1
figure 1

PRISMA diagram showing identification of included studies

Full size image

Risk of bias in included studies

The quality of all included studies was moderate to poor and most studies had similar flaws (Table 1). For the qualitative analysis the trials were assigned to 2 broad groups: pharmacological techniques and anesthetic techniques. There were no studies that compared or utilized multimodal pain interventions.

Table 1 Methodological quality summary and level of evidence (LoE)
Full size table

Pharmacological interventions

The trials assessing analgesic interventions were grouped into conventional analgesics (non-selective non-steroidal anti-inflammatory drugs (NSAIDs), cyclooxygenase (COX) 2-selective inhibitors, lidocaine, and opioids); adjunct drugs with analgesic activity (α2 agonists, α2δ ligands [gabapentin and pregabalin], muscarinic receptor antagonists and N-methyl-D-aspartic acid [NMDA] antagonists [magnesium and ketamine]) (Table 2); and regional anesthesia techniques generally showed that these pharmacological approaches were useful (Table 3). Four studies compared epidural analgesia with systemic analgesia, of which two showed a reduction in pain scores (Table 3). Two studies evaluated intrathecal opioids with or without clonidine (Table 3). Both showed improved pain relief, but increased frequency of pruritus was reported in one study.

Table 2 Summary of key results from included studies evaluating pharmacological interventions in patients undergoing radical prostatectomy
Full size table
Table 3 Summary of key results from included studies evaluating local/regional analgesia techniques in patients undergoing radical prostatectomy (a indicates laparoscopic or robotic approach)
Full size table

Surgical techniques

Although a minimally invasive approach for radical prostatectomy has been rapidly adopted in clinical practice [3, 4], there are only 4 RCTs assessing pain management. Moreover, between October 2012 and June 2015, only 2 additional RCT have been published assessing pain control using a robotic approach [49, 50]. These studies focused on adjunct techniques (i.e., penile block to improve bladder catheter tolerance [49] and intravesical ropivacaine [50]) and both did not result in any improvement in pain control.

Anesthetic techniques

Three studies investigating the use of regional anesthesia, including combined procedures with general anesthesia, showed a reduction of analgesic supplemental use with regional anesthesia (Table 4). However, the differences between groups with regard to pain scores were inconclusive. Two studies compared spinal anesthesia with general anesthesia. Patients receiving spinal anesthesia had significantly shorter durations of surgery, reduced blood loss and lower pain scores on the day of surgery than patients receiving general anesthesia.

Table 4 Summary of key results from included studies evaluating anesthetic interventions in patients undergoing radical prostatectomy (a indicates laparoscopic or robotic approach)
Full size table

Discussion

This systematic review reveals that there is a significant lack of evidence to develop an optimal pain management protocol in patients undergoing radical prostatectomy. Most studies evaluating pain management after radical prostatectomy surgery assessed unimodal analgesic approaches [11–48]. The optimal dose or timing of administration of analgesic agents could not always be determined. Although it is generally accepted that minimal access surgery for radical prostatectomy reduces postoperative pain, it is poorly studied.

Pain after laparoscopic/robotic prostatectomy is generally mild-to-moderate [7]. A recent observational, prospective cohort study that included a limited number of opioid-naïve patients reported that pain after robotic radical prostatectomy was adequately controlled primarily with NSAIDs and opioids [47]. Because opioids may delay recovery and increase the length of hospital stay [51], due to opioid-related adverse effects such as nausea, vomiting and prolonged postoperative ileus [52], non-opioid analgesics and/or regional analgesic techniques should be used as primary analgesics, and supplemented with opioids, only if necessary.

While we wait for appropriate procedure specific evidence for optimal pain management after minimally invasive radical prostatectomy, a basic analgesic technique, used in observational trials [7], could include a combination of acetaminophen (paracetamol) and NSAID or COX-2 selective inhibitor along with wound infiltration of the trocar sites [5]. The choice between a traditional NSAID and COX-2 selective inhibitors should depend upon assessment of individual patient risks. Non-selective NSAIDs can increase the potential risk of bleeding [53] in contrast to COX-2 selective inhibitors. However, a recent randomized, placebo-controlled, double-blind trial in patients undergoing open prostatectomy reported that while parecoxib reduced opioid use and opioid-related side effects, blood loss at 24 h after surgery was significantly higher in comparison to the placebo group, corresponding to a 1 g/dL difference in hemoglobin [54].

For patients undergoing open prostatectomy under spinal anesthesia, intrathecal morphine may be an appropriate alternative, assuming that proper precautions are taken for prevention of the morphine-related complications such as nausea and vomiting, pruritus, and respiratory depression. This is also supported by two recent studies reporting reduced intravenous opioid requirements after intrathecal morphine (150–200 μg), with a consequent decrease in the incidence of nausea and vomiting [55, 56]. However, there is a lack of data supporting superiority of epidural analgesia for this surgical procedure; two studies in this systematic review reported benefit from epidural analgesia [11, 22], while two studies found no benefit of epidural analgesia over systemic analgesia [27, 31]. A recent study published after the completion of the systematic review reported that epidural analgesia increased by one day, the length of hospital stay and recommended its avoidance [57].

Two recent studies published after the deadline for inclusion in this systematic review, report controversial results concerning the analgesic effect of the transversus abdominis plane (TAP) blocks included in multimodal protocols [58, 59]. One placebo-controlled study published after the deadline of this systematic review reported that postoperative local anesthetic infusion via a subfascially placed wound catheter did not improve pain relief when combined with basic analgesic regimen consisting of acetaminophen and NSAID with opioid used as rescue [60].

The limitations of this systematic review stem from the limitations of the included studies: particularly the inadequate study design (e.g., lack of double-blinding or explicit randomization) and lack of use of simple non-opioid analgesics when comparing more invasive techniques and a failure to evaluate all the potentially relevant analgesic agents and techniques for radical prostatectomy (especially infiltration techniques).

Thus, this review has identified several areas for future research when current data are insufficient or conflicting. There is a need for clinical trials evaluating multimodal analgesia techniques that would include combinations of paracetamol and NSAID/COX-2 selective inhibitor, and regional anesthetic techniques, with oral opioids administered only as rescue postoperatively. Future studies also need to evaluate the benefit to risk of continuous local anesthetic wound infusion and TAP blocks combined with multimodal analgesia. Also, large randomized clinical trials are necessary to assess the efficacy as well as optimal dose and duration of lidocaine intravenous infusion, ketamine and gabapentinoids. A study published after the deadline reported that a single preoperative dose (900 mg) of gabapentin reduced pain scores but not opioid requirements [61].

Future trials should include multimodal enhanced rehabilitation protocols (fast track or enhanced recovery programs) as an integral part of the study design [62]. This will allow us to differentiate the effects of the analgesic interventions on perioperative outcome from those of the enhanced recovery programs that are becoming the standard of care. Also, there is a need for more procedure-specific studies comparing pain and analgesic requirements between open and minimal access (laparoscopic and robotic) surgical procedures.

Conclusions

This systematic review reveals that there is a lack of evidence to develop an optimal pain management protocol in patients undergoing radical prostatectomy. Most studies assessed unimodal analgesic approaches rather than a multimodal technique. There is a need for more procedure-specific studies comparing pain and analgesic requirements for open and minimally invasive surgical procedures. Finally, while we wait for appropriate procedure specific evidence from publication of adequate studies assessing optimal pain management after radical prostatectomy, we propose a basic analgesic guideline.

Abbreviations

PRISMA:

Preferred reporting items for systematic reviews and meta-analyses

RCTs:

Randomized controlled trials

NSAIDs:

Non-steroidal anti-inflammatory drugs

COX-2:

Cyclooxygenase-2

NMDA:

N-methyl-D-aspartic acid

TAP:

Transversus abdominis plane

References

  1. Siegel R, Ward E, Brawley O, Jemal A. Cancer statistics, 2011: the impact of eliminating socioeconomic and racial disparities on premature cancer deaths. CA Cancer J Clin. 2011;61:212–36.

    Article  PubMed  Google Scholar 

  2. Parker C, Gillessen S, Heidenreich A, Horwich A. ESMO Guidelines Committee. Cancer of the prostate: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up. Ann Oncol 2015 Jul 22. [Epub ahead of print].

  3. Liu JJ, Maxwell BG, Panousis P, Chung BI. Perioperative outcomes for laparoscopic and robotic compared with open prostatectomy using the National Surgical Quality Improvement Program (NSQIP) database. Urology. 2013;82:579–83.

    Article  PubMed  Google Scholar 

  4. Autorino R, Kaouk JH, Stolzenburg JU, Gill IS, Mottrie A, Tewari A, et al. Current status and future directions of robotic single-site surgery: a systematic review. Eur Urol. 2013;63:266–80.

    Article  PubMed  Google Scholar 

  5. Joshi GP, Schug S, Kehlet H. Procedure specific pain management and outcomes strategies. Best Prac Res Clin Anaesthesiol. 2014;28:191–201.

    Article  Google Scholar 

  6. D’Alonzo RC, Gan TJ, Moul JW, Albala DM, Polascik TJ, Robertson CN, et al. A retrospective comparison of anesthetic management of robot-assisted laparoscopic radical prostatectomy versus radical retropubic prostatectomy. J Clin Anesth. 2009;21:322–8.

    Article  PubMed  Google Scholar 

  7. Woldu SL, Weinberg AC, Bergman A, Shapiro EY, Korets R, Motamedinia P, et al. Pain and analgesic use after robot-assisted radical prostatectomy. J Endourol. 2014;28:544–8.

    Article  PubMed  Google Scholar 

  8. Magheli A, Knoll N, Lein M, Hinz S, Kempkensteffen C, Gralla O. et al. Impact of fast-track postoperative care on intestinal function, pain, and length of hospital stay after laparoscopic radical prostatectomy. J Endourol. 2011;25:1143–7.

    Article  PubMed  Google Scholar 

  9. Moher D, Liberati A, Tetzlaff J, Altman DG. Reprint-preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Phys Ther. 2009;89:873–80.

    PubMed  Google Scholar 

  10. Higgins JPT, Altman DG, Sterne JAC. Chapter 8: Assessing risk of bias in included studies. In Higgins JPT, Green S (editors):Cochrane Handbook for Systematic Reviews of Interventions. Version 5.1.0 [updated March 2011]. The Cochrane Collaboration, 2011. Available from www.cochrane-handbook.org.

  11. Allaire PH, Messick JM, Oesterling JE, Byer DE, Myers RP, Lieber MM, et al. A prospective randomized comparison of epidural infusion of fentanyl and intravenous administration of morphine by patient-controlled analgesia after radical retropubic prostatectomy. Mayo Clinic Proc. 1992;67:1031–41.

    Article  CAS  Google Scholar 

  12. Andrieu G, Roth B, Ousmane L, Castaner M, Petillot P, Vallet B, et al. The efficacy of intrathecal morphine with or without clonidine for postoperative analgesia after radical prostatectomy. Anesth Analg. 2009;108:1954–57.

    Article  CAS  PubMed  Google Scholar 

  13. Aribogan A, Doruk N, Aridogan A, Akin S, Balcioglu O. Patient-controlled epidural analgesia after major urologic surgeries. A comparison of tramadol with or without bupivacaine. Urol Int. 2003;2:168–75.

    Article  Google Scholar 

  14. Bilgin TE, Bozlu M, Atici S, Cayan S, Tasdelen B. Wound infiltration with bupivacaine and intramuscular diclofenac reduces postoperative tramadol consumption in patients undergoing radical retropubic prostatectomy: a prospective, double-blind, placebo-controlled, randomized study. Urology. 2011;78:1281–85.

    Article  PubMed  Google Scholar 

  15. Borazan H, Tuncer S, Yalcin N, Erol A, Otelcioglu S. Effects of preoperative oral melatonin medication on postoperative analgesia, sleep quality, and sedation in patients undergoing elective prostatectomy: a randomized clinical trial. J Anesth. 2010;24:155–60.

    Article  PubMed  Google Scholar 

  16. Brown DR, Hofer RE, Patterson DE, Fronapfel PJ, Maxson PM, Narr BJ, et al. Intrathecal anesthesia and recovery from radical prostatectomy: a prospective, randomized, controlled trial. Anesthesiology. 2004;100:926–34.

    Article  CAS  PubMed  Google Scholar 

  17. Chelly JE, Ploskanych T, Dai F, Nelson JB. Multimodal analgesic approach incorporating paravertebral blocks for open radical retropubic prostatectomy: a randomized double-blind placebo-controlled study. Can J Anaesth. 2011;58:371–8.

    Article  PubMed  Google Scholar 

  18. Fant F, Axelsson K, Sandblom D, Magnuson A, Andersson SO, Gupta A. Thoracic epidural analgesia or patient-controlled local analgesia for radical retropubic prostatectomy: a randomized, double-blind study. Br J Anaesth. 2011;107:782–9.

    Article  CAS  PubMed  Google Scholar 

  19. Gaitini L, Moskovitz B, Katz E, Vaisberg A, Vaida S, Nativ O. Sublingual buprenorphine compared to morphine delivered by a patient-controlled analgesia system as postoperative analgesia after prostatectomy. Urol Int. 1996;57:227–9.

    Article  CAS  PubMed  Google Scholar 

  20. Gottschalk A, Smith DS, Jobes DR, Kennedy SK, Lally SE, Noble VE, et al. Preemptive epidural analgesia and recovery from radical prostatectomy: a randomized controlled trial. JAMA. 1998;279:1076–82.

    Article  CAS  PubMed  Google Scholar 

  21. Groudine SB, Fisher HAG, Kaufman Jr RP, Patel MK, Wilkins LJ, Mehta SA, et al. Intravenous lidocaine speeds the return of bowel function, decreases postoperative pain, and shortens hospital stay in patients undergoing radical retropubic prostatectomy. Anesth Analg. 1998;86:235–9.

    CAS  PubMed  Google Scholar 

  22. Gupta A, Fant F, Axelsson K, Sandblom D, Rykowski J, Johansson JE, et al. Postoperative analgesia after radical retropubic prostatectomy: a double-blind comparison between low thoracic epidural and patient-controlled intravenous analgesia. Anesthesiology. 2006;105:784–93.

    Article  CAS  PubMed  Google Scholar 

  23. Habib AS, Polascik TJ, Weizer AZ, White WD, Moul JW, Elgasim MA, et al. Lidocaine patch for postoperative analgesia after radical retropubic prostatectomy. Anesth Analg. 2009;108:1950–3.

    Article  CAS  PubMed  Google Scholar 

  24. Habib AS, White WD, El Gasim MA, Saleh G, Polascik TJ, Moul JW, et al. Transdermal nicotine for analgesia after radical retropubic prostatectomy. Anesth Analg. 2008;107:999–1004.

    Article  CAS  PubMed  Google Scholar 

  25. Haythornthwaite JA, Raja SN, Fisher B, Frank SM, Brendler SM, Shir Y. Pain and quality of life following radical retropubic prostatectomy. J Urol. 1999;160:1761–4.

    Article  Google Scholar 

  26. Heid F, Schmidt-Glintzer A, Piepho T, Jage J. Epidural ropivacaine - Where are the benefits? A prospective, randomized, double-blind trial in patients with retropubic prostatectomy. Acta Anaesthesiol Scand. 2007;51:294–8.

    Article  CAS  PubMed  Google Scholar 

  27. Hohwu L, Akre O, Bergenwald L, Tornblom M, Gustafsson O. Oral oxycodone hydrochloride versus epidural anaesthesia for pain control after radical retropubic prostatectomy. Scand J Urol Nephrol. 2006;40:192–7.

    Article  CAS  PubMed  Google Scholar 

  28. Hong JY, Yang SC, Yi J, Kil HK. Epidural ropivacaine and sufentanil and the perioperative stress response after a radical retropubic prostatectomy. Acta Anaesthesiol Scand. 2011;55:282–9.

    Article  CAS  PubMed  Google Scholar 

  29. Huang JJ, Taguchi A, Hsu H, Andriole Jr GL. Preoperative oral rofecoxib does not decrease postoperative pain or morphine consumption in patients after radical prostatectomy: a prospective, randomized, double-blinded, placebo-controlled trial. J Clin Anesth. 2001;13:94–7.

    Article  CAS  PubMed  Google Scholar 

  30. Katz J, Schmid R, Snijdelaar DG, Coderre TJ, McCartney CJL, Wowk A. Pre-emptive analgesia using intravenous fentanyl plus low-dose ketamine for radical prostatectomy under general anesthesia does not produce short-term or long-term reductions in pain or analgesic use. Pain. 2004;110:707–18.

    Article  CAS  PubMed  Google Scholar 

  31. Liu S, Carpenter RL, Mulroy MF, Weissman RM, McGill TJ, Rupp SM, et al. Intravenous versus epidural administration of hydromorphone: effects on analgesia and recovery after radical retropubic prostatectomy. Anesthesiology. 1995;82:682–8.

    Article  CAS  PubMed  Google Scholar 

  32. Mayson KV, Gofton EA, Chambers KG. Premedication with low dose oral clonidine does not enhance postoperative analgesia of intrathecal morphine. Can J Anesth. 2000;47:752–7.

    Article  CAS  PubMed  Google Scholar 

  33. Mazaris EM, Varkarakis I, Chrisofos M, Skolarikos A, Ioannidis K, Dellis A, et al. Use of Nonsteroidal anti-inflammatory drugs after radical retropubic prostatectomy: a prospective, randomized trial. Urology. 2008;72:1293–7.

    Article  PubMed  Google Scholar 

  34. Ormiston MC, Vaughton KC, Thornton EJ. The comparative effectiveness of tiaprofenic acid and aspirin in the treatment of post-prostatectomy pain. Br J Clin Pract. 1981;35:360–2.

    CAS  PubMed  Google Scholar 

  35. Salonia A, Crescenti A, Suardi N, Memmo A, Naspro R, Bocciardi AM, et al. General versus spinal anesthesia in patients undergoing radical retropubic prostatectomy: results of a prospective, randomized study. Urology. 2004;64:95–100.

    Article  PubMed  Google Scholar 

  36. Salonia A, Suardi N, Crescenti A, Colombo R, Rigatti P, Montorsi F. General versus spinal anesthesia with different forms of sedation in patients undergoing radical retropubic prostatectomy: results of a prospective, randomized study. Int J Urol. 2006;13:1185–90.

    Article  PubMed  Google Scholar 

  37. Shir Y, Raja SN, Frank SM. The effect of epidural versus general anesthesia on postoperative pain and analgesic requirements in patients undergoing radical prostatectomy. Anesthesiology. 1994;80:49–56.

    Article  CAS  PubMed  Google Scholar 

  38. Snijdelaar DG, Cornelisse HB, Schmid RL, Katz J. A randomised, controlled study of peri-operative low dose s(+)-ketamine in combination with postoperative patient-controlled s(+)-ketamine and morphine after radical prostatectomy. Anaesthesia. 2004;59:222–8.

    Article  CAS  PubMed  Google Scholar 

  39. Snijdelaar DG, Koren G, Katz J. Effects of perioperative oral amantadine on postoperative pain and morphine consumption in patients after radical prostatectomy: results of a preliminary study. Anesthesiology. 2004;100:134–41.

    Article  CAS  PubMed  Google Scholar 

  40. Tauzin-Fin P, Sesay M, Delort-Laval S, Krol-Houdek MC, Maurette P. Intravenous magnesium sulphate decreases postoperative tramadol requirement after radical prostatectomy. Eur J Anaesthesiol. 2006;23:1055–59.

    Article  CAS  PubMed  Google Scholar 

  41. Tauzin-Fin P, Sesay M, Svartz L, Krol-Houdek MC, Maurette P. Sublingual oxybutynin reduces postoperative pain related to indwelling bladder catheter after radical retropubic prostatectomy. Br J Anaesth. 2007;99:572–5.

    Article  CAS  PubMed  Google Scholar 

  42. Tauzin-Fin P, Sesay M, Svartz L, Krol-Houdek MC, Maurette P. Wound infiltration with magnesium sulphate and ropivacaine mixture reduces postoperative tramadol requirements after radical prostatectomy. Acta Anaesthesiol Scand. 2009;53:464–9.

    Article  CAS  PubMed  Google Scholar 

  43. Wu CL, Partin AW, Rowlingson AJ, Kalish MA, Walsh PC, Fleisher LA. Efficacy of continuous local anesthetic infusion for postoperative pain after radical retropubic prostatectomy. Urology. 2005;66:366–70.

    Article  PubMed  Google Scholar 

  44. Lauwick S, Kim DJ, Mistraletti G, Carli F. Functional walking capacity as an outcome measure of laparoscopic prostatectomy: the effect of lidocaine infusion. Br J Anaesth. 2009;103:213–9.

    Article  CAS  PubMed  Google Scholar 

  45. Hong JY, Lee SJ, Rha KH, Roh GU, Kwon SY, Kil HK. Effects of thoracic epidural analgesia combined with general anesthesia on intraoperative ventilation/oxygenation and postoperative pulmonary complications in robot-assisted laparoscopic radical prostatectomy. J Endourol. 2009;23:1843–9.

    Article  PubMed  Google Scholar 

  46. Lee C, Song YK, Jeong HM, Park SN. The effects of magnesium sulfate infiltration on perioperative opioid consumption and opioid-induced hyperalgesia in patients undergoing robot-assisted laparoscopic prostatectomy with remifentanil-based anesthesia. Korean J Anesthesiol. 2011;61:244–50.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  47. Lukasewycz S, Holman M, Kozlowski P, Porter CR, Odom E, Bernands C, et al. Does a perioperative belladonna and opium suppository improve postoperative pain following robotic assisted laparoscopic radical prostatectomy? Results of a single institution randomized study. Can J Urol. 2010;17:5377–82.

    PubMed  Google Scholar 

  48. Larijani GE, Goldberg ME, Gratz I, Warshal DP. Analgesic and hemodynamic effects of a single 7.5-mg intravenous dose of morphine in patients with moderate-to-severe postoperative pain. Pharmacotherapy. 2004;24:1675–80.

    Article  CAS  PubMed  Google Scholar 

  49. Weinberg AC, Woldu SL, Bergman A, Roychoudhury A, Patel T, Berg W, et al. Dorsal penile nerve block for robot-assisted radical prostatectomy catheter related pain: a randomized, double-blind, placebo-controlled trial. Springerplus. 2014;3:181.

    Article  PubMed Central  PubMed  Google Scholar 

  50. Fuller A, Vanderhaeghe L, Nott L, Martin PR, Pautler SE. Intravesical ropivacaine as a novel means of analgesia post-robot-assisted radical prostatectomy: a randomized, double-blind, placebo-controlled trial. J Endourol. 2013;27:313–7.

    Article  PubMed  Google Scholar 

  51. Gardner TA, Bissonette EA, Petroni GR, McClain R, Sokoloff MH, Theodorescu D. Surgical and postoperative factors affecting length of hospital stay after radical prostatectomy. Cancer. 2000;89:424–30.

    Article  CAS  PubMed  Google Scholar 

  52. Wheeler M, Oderda GM, Ashburn MA, Lipman AG. Adverse events associated with postoperative opioid analgesia: a systematic review. J Pain. 2002;3:159–80.

    Article  PubMed  Google Scholar 

  53. Hegi TR, Bombeli T, Seifert B, Baumann PC, Haller U, Zalunardo MP, et al. Effect of rofecoxib on platelet aggregation and blood loss in gynaecological and breast surgery compared with diclofenac. Br J Anaesth. 2004;92:523–31.

    Article  CAS  PubMed  Google Scholar 

  54. Dirkmann D, Groeben H, Farhan H, Stahl SL, Eikermann M. Effects of parecoxib on analgesia benefits and blood loss following open prostatectomy: a multicentre randomized trial. BMC Anesthesiol. 2015;15:31.

    Article  PubMed Central  PubMed  Google Scholar 

  55. Nuri Deniz M, Erhan E, Ugur G. Intrathecal morphine reduces postoperative tramadol consumption in patients undergoing radical retropubic prostatectomy: a randomized trial. Eur Rev Med Pharmacol Sci. 2013;17:834–8.

    CAS  PubMed  Google Scholar 

  56. Ozbek H, Deniz MN, Erakgun A, Erhan E. Comparison of 75 and 150 μg doses of intrathecal morphine for postoperative analgesia after transurethral resection of the prostate under spinal anesthesia. J Opioid Manag. 2013;9:415–20.

    Article  PubMed  Google Scholar 

  57. Mir MC, Joseph B, Zha R, Bolton DM, Gyomber D, Lawrentschuk N. Effectiveness of epidural versus alternate analgesia for pain relief after radical prostatectomy and correlation with biochemical recurrence in men with prostate cancer. Res Rep Urol. 2013;5:139–45.

    PubMed Central  PubMed  Google Scholar 

  58. Elkassabany N, Ahmed M, Malkowicz SB, Heitjan DF, Isserman JA, Ochroch EA. Comparison between the analgesic efficacy of transversus abdominis plane (TAP) block and placebo in open retropubic radical prostatectomy: a prospective, randomized, double-blinded study. J Clin Anesth. 2013;25:459–65.

    Article  PubMed  Google Scholar 

  59. Skjelsager A, Ruhnau B, Kistorp TK, Kridina I, Hvarness H, Mathiesen O, et al. Transversus abdominis plane block or subcutaneous wound infiltration after open radical prostatectomy: a randomized study. Acta Anaesthesiol Scand. 2013;57:502–8.

    Article  CAS  PubMed  Google Scholar 

  60. Kristensen BS, Fenger-Eriksen C, Pedersen KV, Felsby S. Wound infusion of bupivacaine following radical retropubic prostatectomy: a randomized placebo-controlled clinical study. Acta Anaesthesiol Scand. 2013;30:124–8.

    CAS  Google Scholar 

  61. Deniz MN, Sertoz N, Erhan E, Ugur G. Effects of preoperative gabapentin on postoperative pain after radical retropubic prostatectomy. J Int Med Res. 2012;40:2362–9.

    Article  CAS  PubMed  Google Scholar 

  62. Santa Mina D, Matthew AG, Hilton WJ, Au D, Awasthi R, Alibhai SMH, et al. Prehabilitation for men undergoing radical prostatectomy: a multicentre, pilot randomized controlled trial. BMC Surg. 2014;14:89.

    Article  PubMed Central  PubMed  Google Scholar 

Download references

Acknowledgments

The authors would like to thank Esther Jacobs and Christoph Mosch, Cologne, Germany for assistance with data compilation.

All authors are members of the PROSPECT Working Group, which is supported by Pfizer Inc. New York, NY, USA. The PROSPECT Working Group members have been reimbursed by Pfizer Inc. for attending PROSPECT meetings to formulate the consensus recommendations. This paper makes no specific recommendations about the use of any medical products, drugs or equipment manufactured by Pfizer Inc. or by any of its subsidiaries.

PROSPECT collaboration

Francis Bonnet, Department d’ Anesthesie Reanimation, Hôspital Tenon, Paris, France.

H. Barrie J. Fischer, Department of Anaesthesiology, Alexandra Hospital, Redditch, Worcestershire, UK.

Andrew Hill, Department of Surgery, University of Auckland, Auckland, New Zealand.

Girish P. Joshi, Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, Dallas, TX, USA.

Henrik Kehlet, Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark.

Philipp Lirk, Academic Medical Center, University of Amsterdam, The Netherlands.

Edmund A. M. Neugebauer, Institute of Research in Operative Medicine, University of Witten-Herdecke, Cologne, Germany.

Narinder Rawal, Department of Anaesthesia and Intensive Care, University Hospital, Örebro, Sweden.

Stephan A. Schug, School of Medicine and Pharmacology, University of Western Australia, Perth, Australia.

Christian J. P. Simanski, Department of Trauma and Orthopaedic Surgery Cologne-Merheim, University of Witten-Herdecke, Cologne, Germany.

Marc Van de Velde, Department of Anesthesiology, Leuven, Netherlands.

Marcel Vercauteren, Department of Anesthesiology, University of Antwerp, Antwerpen, Belgium.

Author information

Authors and Affiliations

  1. Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical School, 5323 Harry Hines Blvd, Dallas, TX, 75390-9068, USA

    Grish P. Joshi

  2. Institute for Research in Operative Medicine, Witten/Herdecke University, Cologne, Germany

    Thomas Jaschinski

  3. Department d’ Anesthesie Reanimation, Hôpital Tenon, Assistance Publique Hôpitaux de Paris Université Pierre & Marie Curie, Paris, France

    Francis Bonnet

  4. Section for Surgical Pathophysiology, Rigshospitalet, Copenhagen University, Copenhagen, Denmark

    Henrik Kehlet

Authors
  1. Grish P. Joshi
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Thomas Jaschinski
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Francis Bonnet
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Henrik Kehlet
    View author publications

    You can also search for this author in PubMed Google Scholar

Consortia

on behalf of the PROSPECT collaboration

Corresponding author

Correspondence to Grish P. Joshi.

Additional information

Competing interests

Over the past 5 years: Girish Joshi has received honoraria for consultancy and/or presentation from Pfizer, Mallinkrodt, and Pacira. Francis Bonnet, Narinder Rawal and Henrik Kehlet have received honoraria for consultancy and/or presentation from Pfizer. Francis Bonnet has received honorarium for consultancy and presentation from Nordic Pharma. Barrie Fischer has received honoraria for consultancy and/or presentation from Pfizer, B. Braun and AstraZeneca. Christian Simanski has received honoraria for consultancy and/or presentation from Gruenenthal, Merck, and Biomet. Edmund Neugebauer has received honoraria for consultancy and/or presentation from QRx Pharma, Gruenenthal, Janssen. The Anaesthesiology Unit of UWA, but not Stephan Schug privately, has received research and consultancy funding from Gruenenthal, CSL, Janssen Pharmaceuticals, Mundipharma, Pfizer, Phosphagenics and Biopharma.

Authors’ contributions

Girish Joshi: Participated in conception and design of study, interpretation of data, and drafting and revising the manuscript. Thomas Jaschinski: Participated in the acquisition and analysis of data. Francis Bonnet: Participated in conception and design of study, interpretation of data, and drafting and revising the manuscript. Henrik Kehlet: Participated in conception and design of study, interpretation of data, and drafting and revising the manuscript. All authors read and approved the final manuscript.

Rights and permissions

Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Joshi, G.P., Jaschinski, T., Bonnet, F. et al. Optimal pain management for radical prostatectomy surgery: what is the evidence?. BMC Anesthesiol 15, 159 (2015). https://doi.org/10.1186/s12871-015-0137-2

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s12871-015-0137-2

Keywords

BMC Anesthesiology

ISSN: 1471-2253

Contact us