Efficacy of liposomal bupivacaine versus bupivacaine with steroids for postoperative pain control in minimally invasive nephrectomies - a single center retrospective study
Stephanie Hanchuk, MD, Kaivon Sobhani, MD, Mark Hocevar, BA, Benjamin Press, MD, Jinlei Li, MD.
Yale School of Medicine, New Haven, CT, USA.
Minimally invasive nephrectomy is one of the most performed surgical procedures in urologic oncology. Perioperative nerve blocks are increasingly adopted with the goal of improving pain control and decreasing opioid use. Liposomal bupivacaine was introduced in 2011 with the goal of improving analgesic duration, however, the results of randomized trials are conflicting. Nonetheless, liposomal bupivacaine for surgical site infiltration continues to be used at an added financial cost. Glucocorticoids have been used off-label in both local infiltration and nerve block multimodal analgesia. The goal of our retrospective study was to assess the post-operative analgesic efficacy of perioperative truncal blocks using liposomal bupivacaine versus plain bupivacaine plus steroids (dexamethasone and methylprednisolone) versus surgical site local anesthetic infiltration (no block) in patients who underwent minimally invasive nephrectomies.
In this retrospective cohort study, all minimal invasive nephrectomies (partial and radical) in a single academic health system between January 2018 and December 2022 were reviewed. Based on surgical approach, patients received no nerve block or ultrasound guided truncal blocks including transversus abdominus plane (TAP), quadratus lumborum (QL), or rectus sheath blocks with either bupivacaine plus glucocorticoids or liposomal bupivacaine. The primary outcome measured was post-operative opioid use. The secondary outcomes measured were postoperative pain scores, postoperative adverse events, and hospital length of stay.
Results141 patients were included. No significant difference was found in demographics, procedure type, or co-morbidities between the liposomal bupivacaine, bupivacaine plus glucocorticoid, and no block groups(Table 1 & 4). No significant difference was found in post-operative opioids use (converted to milligram morphine equivalents), operative time, or length of stay (Table 2 & 3). However, patients who received bupivacaine plus steroids had less pain at rest and with activity when compared to the liposomal bupivacaine and control groups (Table 3). Patients who received steroids with their block were also less likely to require opioids 24-48 hours postoperatively (Table 2).
These findings suggest that plain bupivacaine with steroids can be used as a cost effective and commonly available alternative to liposomal bupivacaine. Additionally, truncal blocks with bupivacaine plus glucocorticoids may decrease the need for opioids after postoperative day one and improve postoperative pain scores in patients undergoing minimally invasive urologic procedures. We aim to use data from this study to inform a future randomized controlled trial at our institution.
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