A Multi-Institutional Assessment of Multimodal Analgesia in Penile Implant Recipients Demonstrates Dramatic Narcotics Reduction
Lael Reinstatler, MD MPH1, Jacob Lucas, DO2, Martin S. Gross, MD3, Faisal A. Yafi, MD4, Farouk M. El-Khatib, MD4, Kenneth J. DeLay, MD5, Jay Simhan, MD2.
1Dartmouth-Hitchcock Medical Center, Lebanon, NH, USA, 2Einstein Healthcare Network, Philadelphia, PA, USA, 3Dartmouth-Hitchcock Medical Center/Dartmouth-Hitchcock Keene, Keene, NH, USA, 4University of California Irvine, Orange, CA, USA, 5Advanced Urology Institute, Tallahassee, FL, USA.
BACKGROUND: Increasing regulations are being placed on providers in an effort to combat the growing opioid epidemic in the United States. Although implantation of an inflatable penile prosthesis (IPP) is associated with significant post-operative pain, there have been few rigorous attempts at describing non-opioid based pain management strategies for implant recipients. Here, we present results of a multi-institutional assessment of a multimodal analgesic (MMA) regimen in patients (pts) undergoing IPP surgery to a matched cohort of pts treated with a traditional opioid-based (OB) regimen.
METHODS: We performed a multicenter comparison of pts undergoing IPP implantation by high-volume implanters whose pain was managed using a recently described, novel MMA protocol (Table 1) to a matched, historic cohort of pts managed via an OB protocol. Patients were excluded if they underwent any additional procedure or had a history of narcotic dependence. Both groups were compared with respect to visual analog pain scale (VAS), and opioid usage (total morphine equivalents, TME) in the post-anesthesia care unit (PACU), post-operative days (POD) zero and one, and in immediate post-discharge period. Narcotics usage on discharge and follow up were assessed and compared between both groups.
RESULTS: 91 pts were eligible for final analysis: 53 (58%) in MMA arm and 38 (42%) in the OB arm. There were no differences between groups with regards to age, race, BMI, or medical comorbidities. VAS was significantly lower in the MMA group in PACU (mean 1.1 vs 2.9, p=0.002), POD0 (mean 2.8 vs 4.7, p=0.001), and POD1 (mean 3.02 vs 4.00, p=0.04). Patients in the MMA group used fewer narcotics in the PACU (mean 1.6 vs 4.3 TME, p=0.002), POD0 (mean 5.8 vs 13.8 TME, p<0.001), and POD1 (mean 10.8 vs 25.1 TME, p=0.001). Despite being discharged with substantially fewer narcotics (mean 14.9 vs 51.3 tabs, p<0.001), a smaller proportion of MMA pts required narcotic refills (7.5% vs 47.4%, p<0.001). No pts in either group experienced significant medication-related side-effects.
CONCLUSIONS: To our knowledge, this is the first multicenter pain management investigation in penile implant recipients. The use of a multimodal analgesic protocol not only demonstrates excellent durability in significantly reducing post-operative pain but further reduces inpatient and outpatient narcotic usage without any discernable side-effects.
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