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Objective Pain Assessment After Ureteral Reimplantation: Comparison of Open Versus Robotic Approach
Miriam Harel, MD1, Katherine Herbst, MSc1, Renee Silvis, BS1, John H. Makari, MD2, Fernando A. Ferrer, MD2, Christina Kim, MD2.
1Connecticut Children's Medical Center, Hartford, CT, USA, 2Connecticut Children's Medical Center/University of Connecticut Health Center, Hartford/Farmington, CT, USA.

BACKGROUND:
Most studies comparing open and minimally invasive surgery focus on length of hospital stay and narcotic requirements as a surrogate for measuring postoperative pain. We sought to objectively compare postoperative pain in children undergoing open versus robotic ureteral reimplantation. This was done based on pain assessment scales.
METHODS:
We analyzed a prospective cohort of all patients undergoing surgical intervention for primary vesicoureteral reflux (VUR) between July 2010 and February 2013. Patients who underwent endoscopic treatment or who received caudal or epidural anesthesia were excluded. Pain was assessed using age-appropriate pain scales ranging from zero to ten. The FLACC Scale (Face, Legs, Activity, Cry, Consolability) was used in nonverbal patients, the Wong-Baker FACES Pain Rating Scale was used in patients aged four and older, and the Visual Analog Scale was used in patients aged eight and older. Pain scores and narcotic doses administered on the first postoperative day were analyzed. Pain was categorized as mild (1-3), moderate (4-6), or severe (7-10). All narcotic analgesics were converted to morphine equivalents. Fischer’s Exact Test or t-test were used to compare postoperative pain after open versus robotic surgery.
RESULTS:
Cohort descriptions are displayed in table 1. Mean age at surgery was 6.3 years (+ 4.0) in the open surgery cohort and 8.2 years (+ 2.9) in the robotic group. Ketorolac was administered to all but one patient. Patients had decreased postoperative pain after robotic versus open reimplantation. Due to small sample size, this difference approached but did not reach statistical significance. (p = 0.13) However, this difference is clinically significant, as 56.5% of patients in the robotic cohort had mild or no postoperative pain compared to 25% of patients after open surgery. Only 8.7% of patients in the robotic cohort had severe postoperative pain compared to 41.7% of patients after open surgery. Significantly lower morphine equivalents were administered after robotic surgery versus open surgery. (p < 0.05) Four patients (17.4%) did not require any narcotic analgesics after robotic surgery, compared with one patient (8.3%) in the open surgery cohort.
CONCLUSIONS:
Our series demonstrated decreased postoperative pain after robotic reimplantation compared to open surgery, not only by narcotic requirements but also with an objective pain assessment tool. Ketorolac was administered almost uniformly and likely did not impact the difference in pain scores and narcotic requirements between open and robotic surgery.
Table 1- Cohort descriptions
Variable (n, %)Open reimplantationRobotic reimplantation
Patients12 (34.3%)23 (65.7%)
Bilateral reimplantation9 (75%)10 (43.5%)
Female8 (66.7%)19 (82.6%)
Male4 (33.3%)4 (17.4%)
Pain assessment: No pain (score 0)2 (16.7%)8 (34.8%)
Mild pain (scores 1-3)1 (8.3%)5 (21.7%)
Moderate pain (scores 4-6)4 (33.3%)8 (34.8%)
Severe pain (scores 7-10)5 (41.7%)2 (8.7%)
Mean morphine equivalents/kg (SD)0.13 (+ 0.09)0.06 (+ 0.04)


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