InTrathecal mORphine, traNsversus Abdominis Plane Block, and tramaDOl Infusion for Catheter-Related Bladder Discomfort in Patients Undergoing Robot-Assisted Laparoscopic Prostatectomy (TORNADO): A Pilot Prospective Controlled Study

Evaluation of neuraxial analgesia on outcomes for patients undergoing robot assisted abdominal surgery

STUDY OBJECTIVE

Following robot assisted abdominal surgery, the pain can be moderate in severity. Neuraxial analgesia may decrease the activity of the detrusor muscle, reduce the incidence of bladder spasm and provide effective somatic and visceral analgesia. In this systematic review, we assessed the role of neuraxial analgesia in robot assisted abdominal surgery.

DESIGN

Systematic review.

SETTINGS

Robot assisted abdominal surgery.

PATIENTS

Adults.

INTERVENTIONS

Subsequent to a search of the electronic databases, observational studies and randomized controlled trials that assessed the effect of neuraxial analgesia instituted at induction of anesthesia or intraoperatively in adult and robot assisted abdominal surgery were considered for inclusion. The outcomes of observational studies as well as randomized controlled trials which were not subjected to meta-analysis were presented in descriptive terms. Meta-analysis was conducted if an outcome of interest was reported by two or more randomized controlled trials.

MAIN RESULTS

We included 19 and 11 studies that investigated spinal and epidural analgesia in adults, respectively. The coprimary outcomes were the pain score at rest at 24 h and the cumulative intravenous morphine consumption at 24 h. Spinal analgesia with long acting neuraxial opioid did not decrease the pain score at rest at 24 h although it reduced the cumulative intravenous morphine consumption at 24 h by a mean difference (95%CI) of 14.88 mg (-22.13--7.63; p < 0.0001, I2 = 50%) with a low and moderate quality of evidence, respectively, on meta-analysis of randomized controlled trials. Spinal analgesia with long acting neuraxial opioid had a beneficial effect on analgesic indices till the second postoperative day and a positive influence on opioid consumption up to and including the 72 h time point. The majority of studies demonstrated the use of spinal analgesia with long acting neuraxial opioid to lead to no difference in the incidence of postoperative nausea and vomiting, and the occurrence of pruritus was found to be increased with spinal analgesia with long acting neuraxial opioid in recovery but not at later time points. No difference was revealed in the incidence of urinary retention. The evidence in regard to the quality of recovery-15 score at 24 h and hospital length of stay was not fully consistent, although most studies indicated no difference between spinal analgesia and control for these outcomes. Epidural analgesia in robot assisted abdominal surgery was shown to decrease the pain on movement at 12 h but it had not been studied with respect to its influence on the pain score at rest at 24 h or the cumulative intravenous morphine consumption at 24 h. It did not reduce the pain on movement at later time points and the evidence related to the hospital length of stay was inconsistent.

CONCLUSIONS

Spinal analgesia with long acting neuraxial opioid had a favourable effect on analgesic indices and opioid consumption, and is recommended by the authors, but the evidence for spinal analgesia with short acting neuraxial opioid and epidural analgesia was limited.

Comparison between the Efficacy of Sacral Erector Spina Plane Block and Pudendal Block on Catheter-Related Bladder Discomfort: A Prospective Randomized Study

Objective: Catheter-related bladder discomfort (CRBD) due to indwelling urinary catheterization in patients undergoing transurethral resection of the prostate (TURP) is difficult to tolerate and needs to be treated. This randomized prospective study aimed to compare the efficacy of sacral erector spinae plane block (SESPB) and pudendal nerve block (PNB) in reducing the incidence and score of CRBD. Methods: This study was conducted between November and December 2023. ASA I-III, fifty-four TURP patients were divided into two groups: Group 1 received SESPB (n = 27) and Group 2 received PNB (n = 27) under ultrasound guidance at the end of surgery. The incidence of CRBD, CRBD score, numerical rating scale (NRS) score, use of rescue analgesics, block performance time, first call for analgesics, patient satisfaction, and side effects were recorded for 24 h. Results: The incidence of CRBD was lowest at 33.3% and highest at 48.1% in Group 1 and lowest at 25.9% and highest at 48.1% in Group 2, with no significant difference between the groups at all measurement times. CRBD scores and NRS scores were low and similar between the two groups. Block performance times were 9 ± 1.7 min in SESPB and 20 ± 2.5 min in PNB, and there was a significant difference between the mean times (p < 0.001). Patient satisfaction was adequate and similar in both groups. Conclusions: SESPB demonstrated a similar decreasing effect to PNB on the incidence and scores of CRBD in the first 24 h following TURP operations. The duration of SESPB administration was shorter than PNB.

Intrathecal Morphine and Post-Operative Pain Relief in Robotic Surgeries: A Systematic Review and Meta-Analysis

Despite the potential benefits of intrathecal morphine (ITM), the precise role and dosing of ITM in robotic assisted surgery (RAS) remains unclear. This systematic review explores real-world evidence to evaluate the efficacy and outcomes of ITM in patients undergoing RAS. In accordance with PRISMA guidelines, a comprehensive search was conducted on four databases: MEDLINE, Embase, Cochrane Library and APA PsycInfo. Primary outcomes included pain scores at rest and on exertion at 24- and 48-h time intervals, and secondary outcomes aimed to explore the side effects of ITM. A meta-analysis was conducted to determine mean differences. A risk of bias assessment was conducted via the Cochrane Risk of Bias 2 tool. A total of 9 RCTs involving 619 patients were included in this review, of which 298 patients were administered ITM. Significant pain score reductions were observed both at rest (MD = -27.15; 95% CI [-43.97, -10.33]; I2 = 95%; p = 0.002) and on exertion (MD = -25.88; 95% CI [-37.03, -14.72]; I2 = 79%; p = 0.0003) 24 h postoperatively in the ITM groups, accompanied by a notable decrease in postoperative IV morphine equivalent consumption at 24 h (MD = -20.13; 95% CI [-30.74, -9.52]; I2 = 77%; p = 0.0002). ITM improved pain scores both at rest and on exertion at 24 and 48 h intervals, concurrently reducing the need for postoperative opioid consumption, but at the cost of an increased incidence of adverse events.

Relationship between Middle Cerebral Artery Pulsatility Index and Delayed Neurocognitive Recovery in Patients undergoing Robot-Assisted Laparoscopic Prostatectomy

A steep Trendelenburg (ST) position combined with pneumoperitoneum may cause alterations in cerebral blood flow with the possible occurrence of postoperative cognitive disorders. No studies have yet investigated if these alterations may be associated with the occurrence of postoperative cognitive disorders. The aim of the study was to evaluate the association between an increased middle cerebral artery pulsatility index (Pi), measured by transcranial doppler (TCD) 1 h after ST combined with pneumoperitoneum, and delayed neurocognitive recovery (dNCR) in 60 elderly patients undergoing robotic-assisted laparoscopic prostatectomy (RALP). Inclusion criteria were: ≥65 years; ASA class II-III; Mini-Mental Examination score > 23. Exclusion criteria were: neurological or psychiatric pathologies; any conditions that could interfere with test performance; severe hypertension or vascular diseases; alcohol or substance abuse; chronic pain; and an inability to understand Italian. dNCR was evaluated via neuropsychological test battery before and after surgery. Anesthesia protocol and monitoring were standardized. The middle cerebral artery Pi was measured by TCD, through the trans-temporal window and using a 2.5 MHz ultrasound probe at specific time points before and during surgery. In total, 20 patients experiencing dNCR showed a significantly higher Pi after 1 h from ST compared with patients without dNCR (1.10 (1.0-1.19 95% CI) vs. 0.87 (0.80-0.93 95% CI); p = 0.003). These results support a great vulnerability of the cerebral circulation to combined ST and pneumoperitoneum in patients who developed dNCR. TCD could be used as an intraoperative tool to prevent the occurrence of dNCR in patients undergoing RALP.