Pain management after benign gynecological surgery has attracted renewed interest following the FDA’s warnings about misuse and abuse of immediate-release opioids. Minimally invasive surgery is commonly promoted as a way to reduce postoperative pain.

For treatment of pelvic organ prolapse, though, vaginal and laparoscopic hysterectomy appear to be similar concerning postoperative pain medication requirements. Vatche A. Minassian, MD, MPH, and Iwona Gabriel, MD, PhD, of the Division of Urogynecology at Brigham and Women’s Hospital, elaborate on that conclusion in the International Urogynecology Journal.

Methods

The researchers retrospectively studied 195 women who had surgery for pelvic organ prolapse between 2014 and 2019 at the Brigham or Massachusetts General Hospital:

• Vaginal hysterectomy with vaginal high uterosacral suspension (VH, n=98)
• Laparoscopic supracervical hysterectomy with sacrocolpopexy (LH, n=97)

The two groups were similar in age and body mass index. Duration of surgery, estimated blood loss, and length of hospital stay were all significantly greater in the VH group.

Intraoperative Pain Medication

The amount of narcotics administered during surgery was the same in the two groups: 25 morphine milligram equivalents (MME). However, the use of other pain medications was higher in the LH group:

• Intravenous lidocaine—60 mg in the LH group vs. 40 mg in the VH group (P<0.001)
• Local bupivacaine—50 vs. 20 mL (P<0.001)

Postoperative Pain Medication

Adjusted analyses examined the use of pain medication from completion of surgery to discharge home. These were controlled for race, parity, route of surgery, amount of intraoperative lidocaine and bupivacaine, duration of surgery, estimated blood loss and recovery time.

The route of surgery did not influence the use of narcotics, acetaminophen, ketorolac, or ibuprofen in the immediate period after surgery, even during the first 12 hours.

Instead, the main factor influencing the use of those medications was recovery time. For every additional hour of hospital stay, patients on average used an additional 2 MME of narcotics, 80 mg of acetaminophen, 1 mg of ketorolac, and 20 mg of ibuprofen (P<0.001 for all).

Parity was also linked to narcotic use. Every unit of parity increase resulted in 5 less MME of narcotics (P<0.001).

An Important Limitation

During the study period, there was no standardized protocol at the hospitals for intraoperative anesthesia, and variations may have resulted in different postoperative pain requirements by the surgical route. Prospective, controlled studies with uniform intraoperative pain management will be necessary to answer whether TVH versus LH are associated with less use of postoperative medication, including after discharge.