Prospective evaluation of pain medication requirements and recovery after radical perineal prostatectomy

Objectives. To perform a study to quantify the variables relating to postoperative pain, activity, and gastrointestinal function after radical perineal prostatectomy to allow comparisons with alternative treatments. Methods. Ninety-eight consecutive radical perineal prostatectomy candidates between January 2001 and December 2001 with clinically localized prostate cancer were prospectively evaluated. The time to tolerate solid food, time to unassisted ambulation, postoperative pain levels (analog pain scale of 1 to 10), and perioperative analgesic requirements (in morphine equivalents) were selected as the analysis endpoints and correlated with preoperative (age, American Society of Anesthesiology class, body mass index, and serum prostate-specific antigen level), intraoperative (node dissection, operating room time, and estimated blood loss), and postoperative (Gleason score, tumor stage, and lower extremity neurapraxia) patient variables. Results. The mean time to tolerate solid food and unassisted ambulation was 21.2 ± 1.4 and 22.4 ± 0.8 hours, respectively; 25.5% of patients experienced transient lower extremity neurapraxia, which was associated with longer operative times (P = 0.001). In a multivariate regression analysis, lymph node dissection correlated with both a prolonged time to tolerate solid food (P = 0.002) and unassisted ambulation (P = 0.001) and neurapraxia with an extended time to unassisted ambulation (P = 0.018). The narcotic requirements were greatest on postoperative day 1, totaling 31.7 ± 3.0 morphine equivalents, of which 90.5% ± 3.1% were met with oral analgesics. The average maximal pain scores were highest the first week after discharge (4.7 ± 0.3), yet approached baseline levels by 4 weeks (1.7 ± 0.2) after surgery at which time no patient required any pain medication. Conclusions. Modern radical perineal prostatectomy offers a favorable outcome profile with early patient recovery and low narcotic requirements. A future prospective study should directly compare radical perineal, retropubic, and laparoscopic prostatectomy to document whether the latter offers any advantages with respect to these outcome parameters.