The Effect of Intraperitoneal Bupivacaine on Postoperative Pain Control in Patients Undergoing Pelvic Organ Prolapse Repair: A Double-Blind Randomized Controlled Trial

INTRODUCTION: Enhanced recovery after surgery (ERAS) is a multimodal perioperative approach to surgical recovery that has been shown to lead to early recovery and improved outcomes. One of the primary objectives of ERAS programs is appropriate pain control with a reduction in postoperative opiate consumption typically utilizing non-steroidal anti-inflammatory drugs, acetaminophen, and local anesthesia. For patients undergoing pelvic organ prolapse (POP) repair following ERAS protocols, their post-discharge recovery is greatly improved, and postoperative opiate consumption is significantly decreased. However, the use of intraperitoneal local anesthesia for postoperative pain control in urogynecology remains under-investigated. OBJECTIVE: The purpose of this study is to evaluate the effects of intraperitoneal bupivacaine without epinephrine on postoperative pain control in patients undergoing surgery for POP. METHODS: This double-blind randomized controlled trial compares intraperitoneal bupivacaine versus placebo for postoperative pain control in patients undergoing POP surgery. The primary outcome was pain scores based on a 10-point numeric rating scale (NRS) at 4 hours post-surgery. Secondary outcomes included pain scores based on the NRS collected at 8, 12, and 24 hours post-surgery, postoperative opiate consumption during inpatient stay, time to first narcotic dose during inpatient stay, and hospital length of stay. Patients were randomized 1:1 to the two pain control strategies. All participants underwent uterosacral ligament suspension or sacrocolpopexy. They received either 30 mL of 0.25% bupivacaine or 30 mL of saline via intraperitoneal lavage immediately prior to loss of peritoneal access, and the solution was left in the abdomen upon completion of the procedure. Preoperatively and postoperatively, patients received a standardized pain control regimen of ibuprofen and acetaminophen in accordance with the hospital ERAS protocol. As-needed narcotics were available if pain was poorly controlled on the initial regimen. Pain scores were measured at approximately 4, 8, 12, and 24 hours after completion of the procedure using the NRS. Postoperative opiate consumption, time to first narcotic dose, and hospital length of stay were obtained from the hospital electronic medical record. RESULTS: Ninety-one participants were randomized into treatment (N=44) or placebo (N=47) groups. No differences in demographic or baseline characteristics, surgical time, estimated blood loss, or intraoperative complications were observed between groups. The primary outcome, NRS pain scores at 4 hours post-surgery, showed no statistically significant difference between groups. Similarly, no significant differences were found in NRS scores at 8, 12, or 24 hours post-surgery, total postoperative opiate consumption, time to first narcotic dose during inpatient stay, or hospital length of stay. On average, patients in the placebo and treatment groups underwent 5.45 and 5.23 concomitant surgeries, respectively (Figure 1). CONCLUSIONS: In conclusion, no differences in pain scores, opiate consumption, time to first narcotic dose, or hospital length of stay were observed between the treatment and placebo groups. The routine use of intraperitoneal bupivacaine following pelvic organ prolapse surgery appears to have limited clinical utility (Table 1).