Elimination of Postoperative Narcotics in Infant Robotic Pyeloplasty Using Caudal Anesthesia and a Non-Narcotic Pain Pathway

Abstract

Introduction:

Research suggests that narcotic pain medications are dramatically overprescribed. We hypothesize that narcotics are unnecessary for postoperative pain control in most infants undergoing robotic pyeloplasty. In this series, we report our experience combining caudal blocks with a non-narcotic postoperative pathway as a means of eliminating postoperative narcotics after infant robotic pyeloplasty.

Methods:

We reviewed 24 consecutive patients who underwent robotic pyeloplasty by a single surgeon treated with an end-procedure caudal block followed by a non-narcotic postoperative pain pathway treated between May 2017 and May 2021. The standardized postoperative pathway consisted of an end-procedure caudal block followed by alternating intravenous acetaminophen and ketorolac. We reviewed demographics, outcomes, and unscheduled health care encounters within 30 postoperative days.

Results:

Sixty-three percent (15/24) of patients were male and average age was 12.1 months (range 4–34 months). Fifty-eight percent (9/15) underwent surgery on the left, and 16.7% (4/24) of patients received a single postoperative dose of narcotics in the postanesthesia care unit. No patient required narcotic prescriptions at discharge or anytime thereafter. The average length of stay was 1.13 days. There was no pain-related unscheduled visits or phone calls after discharge.

Conclusions:

This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. Postprocedure caudal block is a good addition to a non-narcotic pathway. In the future, we intend to expand these findings to other pediatric urologic procedures in the hope of eliminating unnecessary narcotic use.

Introduction

Research suggests that narcotic pain medications are dramatically overprescribed.^1
–3 Postoperative non-narcotic pathways (NNPs) are becoming more common within the surgical field to minimize the unnecessary use of narcotics, while still adequately treating pain. The American Pain Society supports these pathways in their 2016 Guidelines on the Management of Postoperative Pain consensus statement, which encourages physicians to use a multimodal approach involving continuous postoperative non-narcotic analgesics.⁴

The side effects and addictive nature of opiates, along with recent shortages, further support the identification of feasible NNPs.⁵ NNPs commonly involve scheduled non-narcotic agents in isolation or in addition to a regional anesthetic blockade. Most importantly, successful pathways must adequately control pain from the patient's perspective.

Pyeloplasty is the surgical procedure of choice to manage ureteropelvic junction obstruction in the pediatric population. Postoperative pain from pediatric pyeloplasty has traditionally been managed with the aid of postoperative narcotics with or without the addition of regional blockade.⁶ Choices for effective regional blockade include caudal, transverse abdominis plane, and paravertebral blockade.^7
–9 Commonly used agents for blockade include lidocaine, marcaine, ropivacaine, and bupivacaine.

The use of a caudal block in open pyeloplasties has previously been shown to decrease the use of opiates and facilitate earlier hospital discharge in patients.⁶ Currently, there are limited data on the use of caudal blockade for robotic pyeloplasties. Caudal blockade has been shown to be a safe procedure with only rare complications including dural puncture, vessel perforation, and subcutaneous infiltration.¹⁰

Previous research has shown that the use of an NNP after pediatric robotic pyeloplasty can result in significantly decreased usage of narcotics and decreased length of postoperative stay compared with a classical narcotic pathway.¹¹ The objectives of this study were twofold: first, to describe our standardized NNP and present it as a model for potential adoption at other institutions. Second, to review our outcome data using this protocol to describe what has been noted as anecdotally effective for years. We aim to confirm the validity and utility of an NNP for infant robotic pyeloplasty and further supplement this with the addition of an immediate postoperative caudal block. Ultimately, we hope to demonstrate that postoperative narcotics are unnecessary after infant robotic pyeloplasty.

Methods

Waiver of HIPPA authorization for research was given in this IRB approved study (IRB 2019-260) so long as research records will be recorded in a manner that does not identify the human subject. We performed a retrospective chart review on 24 consecutive pediatric patients who underwent unilateral robotic dismembered pyeloplasty with ureteral stent by a single surgeon between May 2017 and May 2021 at a single institution. All patients were 4 years of age or younger at the time of surgery. All cases were performed with the da Vinci Xi using three 8 mm robotic trocars. We place our initial camera port using a cutdown method through an incision in the midline of the umbilicus and identifying the natural opening in the umbilical fascia. Additional ports are placed subxiphoid and one in the midaxillary line above the bladder. Intraoperatively, a hitch stitch is placed through the anterior abdominal wall for retraction of the renal pelvis.

This eliminates the need for an assistant port. The Double-J ureteral stent is passed through an angiocatheter on the abdominal wall. Sutures are passed through the robotic ports. An oral gastric tube is placed intraoperatively and removed before the end of the case. Upon surgical completion, a regional caudal blockade, which is the regional blockade of choice with our anesthesia staff, was performed by a pediatric anesthesiologist immediately before cessation of anesthesia. Caudal blockades were completed using bony landmarks, loss of resistance, and negative aspiration test to confirm placement through the sacrococcygeal ligament into the caudal space.

For the caudal block, 1 cc/kg of 0.2%–0.25% ropivacaine was used, which is standard practice at the institution. Narcotic prescribing and administration in the postanesthesia care unit (PACU) were up to the discretion of anesthesia staff and PACU nursing. No intraoperative narcotics were given. Postoperative pain management involved a standardized non-narcotic pain pathway consisting of alternating intravenous (IV) acetaminophen (ofirmev) 15 mg/kg every 6 hours and ketorolac 0.5 mg/kg every 6 hours while inpatient. The first dose of ketorolac was given before the end of the case followed by IV acetaminophen 3 hours later. Patients were assessed in the recovery room and on the floor by nursing staff at least every 2 hours.

If additional pain medication was needed, nursing staff was instructed to call the medical team for narcotic orders. No patient was denied appropriate pain medication. All patients had a Foley catheter that was removed the following morning and a Double-J ureteral stent that was removed 4–6 weeks after surgery. Patients were discharged with instructions to continue alternating over-the-counter acetaminophen and ibuprofen for 24 hours then as needed thereafter. We reviewed demographics, adjunct opioid use, outcomes, and unscheduled health care encounters within 30 days postoperatively.

Results

Patient demographics are listed in Table 1, with 63% (15/24) being male and an average age of 12.1 months (range 4–34 months). The majority, 58% (14/24), underwent surgery on the left. After surgery, 16.7% (4/24) of patients received a single postoperative narcotic dose in the PACU (Table 2). One of these patients who had a concurrent umbilical hernia repair at time of pyeloplasty received one additional dose of hydrocodone–acetaminophen (0.1 mg/kg hydrocodone) immediately upon arrival to the surgical floor, but no other patient required any additional narcotics during their hospitalization. In addition, ondansetron was administered to 16.7% (4/24) of the patients.

Table 1.

Summary of Patient Demographics and Surgical Details

	Average age (months)	Age range (months)	Surgical side	Concomitant procedures
Male (n = 15)	11.7	4–34	Left = 7	N/A
Male (n = 15)	11.7	4–34	Right = 12	1 umbilical hernia repair
Female (n = 9)	12.8	6–16	Left = 7	N/A
Female (n = 9)	12.8	6–16	Right = 2	N/A
Overall (n = 24)	12.1	4–34	Left = 14	—
Overall (n = 24)	12.1	4–34	Right = 10	—

Table 2.

Postoperative Characteristics

	Total patients receiving medications (n = 24)	Mean (unit)	Range (unit)
Narcotics administered in PACU	4/24	0.17 (doses)	0–1 (doses)
Narcotics administered in PACU	16.7%	0.17 (doses)	0–1 (doses)
Narcotics administered during admission	1/24^a	0.04 (doses)	0–1 (doses)
Narcotics administered during admission	4.2%	0.04 (doses)	0–1 (doses)
Antiemetic administered	4/24	NA	NA
Antiemetic administered	16.7%	NA	NA
LOS for all patients	NA	1.13 (days)	1–3 (days)

Underwent concomitant umbilical hernia repair.

LOS = length of stay; PACU = postanesthesia care unit.

No narcotic prescriptions were prescribed at discharge or anytime thereafter within the 30-day review period. The average length of stay was 1.13 days. In the 30 days after surgery, there were no pain-related unscheduled health care encounters including office visits, emergency department visits, primary care visits, hospitalizations, or phone calls after discharge. No adverse events or postoperative complications were noted within this time period as well.

Discussion

Previous studies suggest that medical providers are overprescribing narcotic pain medications for pediatric patients in the postoperative period.^1
–3 Pediatric patients are particularly vulnerable to the harmful effects of opiates. A review of pediatric patients in Tennessee found that 1 out of 2611 patients prescribed opiates had an associated adverse event (emergency visit, hospitalization, or death).¹² An additional study found that between 1997 and 2012, the incidence of opioid poisoning-related hospitalizations in patients of ages 1–4 years old had increased by 205%.¹³

Between 1999 and 2016, the pediatric mortality rate from prescription and illicit opiates had increased by 268.2% to 0.81/100,000.¹⁴ As adult prescribing guidelines have shifted toward reducing opiate usage, there continues to be a lack of specific opioid dosing guidelines for the pediatric population. It is crucial that we evaluate alternative pain management pathways, such as NNPs, to adequately manage patients' pain while limiting the use of unnecessary narcotics. Patients deserve evidence-based medicine that supports pain management while limiting their exposure to unnecessary risks.

Regional anesthetic blocks, with local anesthetics such as lidocaine or marcaine, are commonly used in conjunction with general anesthesia in pediatric patients undergoing various surgical procedures.^9,10 They have been shown to decrease nausea, vomiting, pain levels, general anesthetic levels, and opioid requirements in many pediatric surgeries.¹⁵ The appropriate addition of a regional blockade to an NNP can provide synergistic benefit for pain control. The caudal block is the most common regional block for procedures affecting the lumbosacral and middle thoracic dermatomes.¹⁰

By balancing the effective dose with concentration and volume of the caudal injection, we believe the caudal block can diffuse proximally enough to provide a reasonable block at the subxiphoid incision. The caudal block has been shown to be effective in robot-assisted and laparoscopic surgeries involving the kidneys and upper urinary tracts resulting in reduction of postoperative analgesia.^7,16 An anesthetic blockade at this location is estimated to last for 4–6 hours and can vary depending on the specific medication used as well as the addition of adjuncts to help potentiate the duration of effect.¹⁷

Owing to increased ossification of the sacrococcygeal membrane with aging, there is debate as to the appropriate age up to which caudal blocks can be performed. A feasibility study has shown success with caudal blocks in pediatric patients up to 50 kg, and other studies have used caudal blocks in patients up to 16 years old.^6,18 At our institution, most pediatric anesthesiologists are willing to perform caudal blocks up to the age of 4 years. Our patients were well within the typical age range for caudal block, with an average age of 12.1 months (range 4–21 months).

Concerns surrounding caudal blockade include the risk of dural puncture, vessel perforation, and subcutaneous infiltration. In our series, there were no adverse events noted related to the caudal block. Compared with open approaches, both robotic pyeloplasty and laparoscopic surgery have been shown to be associated with decreased estimated blood loss, shorter postoperative length of stay, and reduced anesthesia requirements.¹⁹

At our institution, laparoscopic pyeloplasty is performed with robotic assistance given the increased dexterity, observation in three dimensions, and ease of suturing. In a small cohort study, Lee et al found that robotic pyeloplasty was associated with decreased total narcotic requirements than open pyeloplasty.²⁰ There is some limited evidence that robotic pyeloplasty is associated with lower opiate use than laparoscopic surgery, but the results so far have not been statistically significant.¹⁹

In an effort to minimize unnecessary postoperative narcotic use, Lee et al. created and evaluated an NNP for robotic pyeloplasty.¹¹ Their pathway involved alternating IV ketorolac and IV acetaminophen every 3 hours, with opiates given as needed for breakthrough pain. Their results showed that 74.5% of patients enrolled in the NNP did not need adjunctive narcotics for pain management. In addition, patients in the NNP pathway received significantly lower doses of narcotics and had shorter postoperative stays than patients in the classical pain management pathway. There were no statistically significant differences in rates of surgical success and postoperative complications.

Piedrahita and Palmer previously evaluated a 1-day discharge pathway for open pyeloplasty after giving periprocedural caudal blocks with postoperative scheduled ketorolac.⁶ Caudal blocks were delivered while the patients were under general anesthesia but before surgical intervention in patients up to age 16 years. This combination was shown to allow for early discharge on postoperative day 1 in 24 of 25 patients (96%), a higher rate than previously reported studies. Their discussion commented that the reduction in postoperative pain could either be because of the caudal block, ketorolac, or the combination.

However, previous studies using ketorolac were not as effective in discharging patients on day 1, suggesting that the combination may be superior to ketorolac alone.⁶ For patients to meet their discharge criteria, it was required that patients' pain be adequately controlled without parenteral narcotics, but they could be sent home on oral acetaminophen with codeine.

Our study is the first to confirm the extended efficacy of an NNP in robotic pyeloplasty by evaluating for unscheduled health care encounters and phone calls within 30 days postoperatively. Obviously, the caudal block works on a much shorter time frame, and one would not expect that pain control issues would persist out to that time frame, but we believe the inclusion of these variables is essential to confirm that we are adequately managing patients' pain in the perioperative period while verifying that there were no surgical complications. The combination NNP with caudal blockade resulted in a cessation of additional narcotic requirements outside of the PACU.

No patient required narcotic prescriptions at discharge or anytime thereafter. There were no pain-related unscheduled health care visits, or phone calls after discharge. A possible limitation is that patients could have sought care elsewhere, but each patient was followed closely and given multiple avenues of contact with the team for any issues or concerns. Despite the association of stent placement with increased postprocedural flank pain, all pain was effectively managed with our pathway.²¹ Anticholinergics were not routinely used. Our data suggest that with the addition of a caudal block in robotic pyeloplasty and the use of IV acetaminophen, postoperative narcotics are not needed and should not be automatically prescribed.

One potential criticism is the use of IV acetaminophen compared with oral formulations; data relating to superiority of IV compared with oral are mixed, though several studies have shown a benefit to IV formulations.^22

–27 Pharmacokinetics have shown more rapid onset and less first pass effect on IV compared with oral.²⁸ In addition, we feel with taste tolerance and postoperative nausea issues that can be common, the IV acetaminophen is beneficial and worth the additional cost.

Despite the associated costs and restricted availability of IV acetaminophen, we believe the benefits of avoiding narcotics are ultimately in the best interest of the patients. For those who do not have IV acetaminophen, oral is a viable option, but IV is preferred in our experience. We hope that IV acetaminophen becomes more accessible with time and more attention is given to expanding its use in the clinical setting.

In conclusion, we believe this study adds to the overall growing body of literature demonstrating the success of NNPs in pediatric surgery. Specifically, narcotic pain medication is generally not needed after pediatric robotic pyeloplasty, either in the immediate postoperative period or for home recovery. Postoperative caudal block appears to be a good augment for immediate postoperative pain control. We believe that narcotics should not be part of routine reflexive postoperative surgical orders.

Furthermore, discharge narcotic prescriptions appear to be unnecessary as well. Limitations to this study include the small sample size and retrospective nature. In the future, we intend to expand these findings to other pediatric procedures in the hope of eliminating unnecessary narcotic use. Further studies are also needed to obtain the lowest doses necessary for the protocol to obtain optimal results. Furthermore, we continue to gather data on this NNP regimen for robotic pyeloplasties with the expectation that the larger series will continue to support our initial findings.

Conclusion

Evidence-based identification of NNPs are essential to reduce unnecessary opioid use. This series shows that a non-narcotic standardized pain management strategy is a viable option for infants undergoing robotic pyeloplasty. The addition of the caudal block to an NNP for robotic pyeloplasty appears to augment this already greatly reduced usage of narcotic medications. Most importantly, patient pain was well managed with this regimen both during hospitalization and after discharge without the need of narcotics. Further research should investigate utilizing similar pathways in other procedures, to reduce and hopefully eliminate unnecessary narcotic usage.

Footnotes

Authors' Contributions

K.M.M. contributed to formal analysis (equal), investigation (equal), methodology (equal), project administration (equal), observation (lead), writing—original (lead), and writing—review and editing (equal). A.Z. was involved in observation (support), writing—original (support), and writing—review and editing (equal). Z.H.R. carried out investigation (equal) and writing—original (support). K.A.A. was involved in investigation (equal) and writing—original (support). M.D.S. carried out formal analysis (equal) and investigation (equal). A.B.B. was involved in conceptualization (equal). Z.J.L. was in charge of conceptualization (equal), formal analysis (equal), methodology (equal), project administration (equal), supervision (lead), validation (lead), writing—original (lead), and writing—review and editing (equal).

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.

Abbreviations Used

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