Objectives: To assess the safety and efficacy of local anesthetic infiltration around nephrostomy tract on postoperative pain control after percutaneous nephrolithotomy. Methods: This systematic review was performed based on randomized clinic trials about local anesthetic infiltration around nephrostomy tract on postoperative pain control. The weighted mean difference (WMD), with their corresponding 95% CI, was calculated to compare continuous variables. Results: Our results showed that the consumption of analgesic was less in the experimental group than in the control group (WMD -25.32, 95% CI -48.09 to -2.55, p = 0.003). There was no significant difference between the mean Visual Analog Scale (VAS) in the experimental group than the control group after 6 h while significantly lower after 24 h. The time of first analgesic demand was significantly longer in the experimental group (WMD 2.19, 95% CI 0.98-3.41). There was no significant difference between 2 groups in terms of operation time, hemoglobin (Hb) alteration, and hospital stay. Conclusion: Local anesthetic infiltration around nephrostomy tract had similar efficacy in the control group in terms of operation time, Hb alteration, and hospital stay, but offers some potential advantages in terms of analgesia requirement, the time of first analgesic demand, and VAS-24 h. However, good quality and large studies with long-term follow-up are warranted for further research.

Percutaneous nephrolithotomy (PCNL) is considered ‘gold standard' for the management of large renal calculi because it is less invasive and morbid than the open surgery. In standard PCNL, a nephrostomy tube with different sizes and types is conventional and thought to be necessary at the end of the procedure to promote urinary drainage and prevent bleeding from the percutaneous tract. However, it can lead to postoperative discomfort and pain. The fear of this pain usually makes patients develop anxiety before the procedure [1]. Postoperative pain was not only related to a comfortable recovery but also related to postoperative complications including pulmonary dysfunction [2]. So the management of postoperative pain is an important part of the care of post operation. Urologists have focused on alleviating postoperative discomfort and pain, which is associated with the nephrostomy tube. Recently, Karatag et al. [3] demonstrated that micro-PCNL is safe, feasible, and efficacious. Pietrow et al. [4] reported that using small caliber catheters after PCNL is associated with lower pain scores in the immediate postoperative period, yet no statistically significant benefit over 6 h. In addition, there is a tendency toward less analgesia requirements. Recently, a meta-analysis that compared tubeless PCNL with standard PCNL has demonstrated decreased postoperative pain in tubeless PCNL [5]. Even more, totally tubeless PCNL without nephrostomy tubes and stents was also demonstrated to be effective and safe and related to decrease in postoperative pain and analgesia requirement [6]. However, tubeless or totally tubeless PCNL could raise the risk of infectious complications post operation because of lack of effective drainage of the urinary system [7]. But the procedures above can be performed only in high-selectivity patients, and were not used widely in clinical treatment. Analgesics such as opioids and nonsteroidal anti-inflammatory drugs have their own side effects and limitations in patients with potential renal problem [8].

Another option to postoperative pain management after PCNL is regional anesthetic techniques. As of now, the infiltration of local anesthetic into percutaneous tract for pain management is being applied by some urologists [9,10]. But the efficacy of local anesthetic infiltration around nephrostomy tract on postoperative pain control is still controversial [9,10,11,12,13]. However, we pooled the data of available studies to conduct a systematic review using meta-analysis to evaluate the role of local anesthetic infiltration around nephrostomy tract on postoperative pain control and determine whether anesthetic infiltration around nephrostomy tract is a better option.

Data Sources and Search Strategy

The meta-analysis was undertaken following the guidelines of the center for reviews and dissemination and preferred reporting items for systematic reviews and meta-analysis (PRISMA) [14]. There was no review protocol for this meta-analysis. For our study, we searched literatures from the Embase, PubMed, Medline, and Cochrane Library from January 2001 to December 2015. All studies about local anesthetic infiltration around the nephrostomy tract on postoperative pain control after PCNL were selected. The following search terms were used: local anesthetic, or bupivacaine, or ropivacaine, or levobupivacaine, or intercostals nerve block, and PCNL. Meanwhile, references of all retrieved studies were searched for further relevant studies. There was no language restriction in the search. When the same cases were reported by multiple studies, we selected the complete or the most recent study for our research.

Study Selection

All studies included in our paper must meet the following criteria: (1) randomized controlled trials (RCTs); (2) patients must undergo PCNL, except tubeless PCNL; (3) the study described at least one outcome of the following: hemoglobin (Hb) alteration, analgesic demand time, total analgesic dose, hospital stay, Visual Analog Scale (VAS) at 6th hour after PCNL (VAS score-6 h), VAS score-24 h; (4) the data from included studies could be used in the meta-analysis directly or could be converted to statistical formula [15]; (5) local anesthetic infiltration around nephrostomy tract must be as an intervention compared with placebo (saline) or a control group. The exclusion criteria were (1) repeated reports; (2) non-RCTs; (3) the data from included studies were not in the appropriate format or could not be obtained from the authors; (3) the full text of the study could not be obtained.

Data Extraction

Two reviewers (C.Z. and B.Y.) independently extracted the data from the eligible studies. The data were cross-checked by the 2 reviewers. Arguments were resolved by discussion. When the 2 reviewers could not reach an agreement, another author (D.T.) participated in a discussion to resolve the dispute and make a final decision by a majority vote. Data were extracted as follows: first author' name, date of publication, sample size, patient characteristics, anesthesia, and measured outcomes.

Risk of Bias Assessment

Risk of bias was evaluated independently by 2 reviewers (G.T. and W.C.) and arguments regarding methodology quality were resolved with a majority vote by 3 reviewers (G.T., W.C., and G.T.). The risk of bias of each trial included assessed by the Cochrane handbook for systematic reviews of interventions [16]. Seven items were assessed as follows: (a) whether the allocation was sequenced adequately, (b) whether the allocation was adequately concealed, (c) whether the patients and personnel were blind from allocation adequately, (d) whether the outcome assessment was blind from allocation adequately, (e) whether incomplete outcome data were adequately addressed, (f) whether reports of the study were free of suggestion of selective outcome reporting, (g) whether the study was free of other problems that could put it at a risk of bias. All the above were classified as ‘low risk of bias,' ‘high risk of bias,' or ‘unclear risk of bias.'

Data Synthesis and Analysis

The meta-analysis was carried out by the use of Review manager version 5.2 software. The weighted mean difference (WMD) with 95% CI was used to calculate the values for continuous variables. And the risk difference with 95% CI was calculated for dichotomous variables. The data were analyzed using the random-effects model because of clinical differences among the studies included (e.g. type of analgesic, inclusion, different anaesthetic, and so on). The Q (chi-square test) and I2 statistics were used to assess heterogeneity. All of the tests were two-sided and p < 0.05 was thought to be statistically significant.

Search Results

From a total of 35 titles, 14 studies were thought to be potentially relevant trials and the papers were read carefully to confirm eligibility. Among the 14 studies, 4 RCTs were excluded for different reasons. Two publications were excluded for lack of complete data. Three publications were excluded because the interventions were different from the topic of our paper. Finally, there were 6 studies that included 358 patients (178 patients with local anesthetic infiltration around the percutaneous tract (the experimental group), and 180 without local anesthetic infiltration around the percutaneous tract (control group)) were determined as appropriated to include into our meta-analysis. The PRISMA flow diagram is present in figure 1.

Fig. 1

PRISMA flow diagram of the systematic literature search.

Fig. 1

PRISMA flow diagram of the systematic literature search.

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Characteristics of Included Studies

All of the 6 were RCTs. They were published in English from 2001 to 2015. Of the 6 articles, 3 were from Turkey, one from India, one from Thailand and one from Canada. The samples size of these trials was in the range 34-105. There were no statistically meaningful differences found for number, age, sex, or stone burden and location. The characteristics of included studies are summarized in table 1.

Table 1

Characteristics of the included studies

Characteristics of the included studies
Characteristics of the included studies

Risk of Bias Assessment

The results of the risk of bias assessments are showed in figure 2. Most studies had low to moderate risk of bias. All included studies were reported randomization. And the method of randomization was not clearly depicted in 2 studies [13,17]. Allocation concealment was adequately conducted in 6 studies. Blinding was described in 5 studies. And 3 of them were double-blinded, the other 2 were single-blinded. There were no other biases found in included studies.

Fig. 2

Risk of bias graph of the included RCTs.

Fig. 2

Risk of bias graph of the included RCTs.

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Main Outcomes

Analgesia Requirement

Ugras et al. [9] did not report the consumption of analgesic in each group, and the study was excluded at final analysis. Finally, 5 RCTs [10,11,12,13,17] with 324 patients in the experimental group (local anesthetic infiltration group) and control group were included for meta-analysis and the random-effects model was used. Pooling data showed a significantly less consumption of analgesics after PCNL in the experimental group than in the control group (WMD -25.32, 95% CI -48.09 to -2.55, p = 0.003; fig. 3a).

Fig. 3

Forest plot presenting the meta-analysis for main outcomes of experimental group vs. control group. a Forest plot presenting the meta-analysis for analgesia requirement. b Forest plot presenting the meta-analysis for the time of first analgesic demand. c Forest plot presenting the meta-analysis for VAS score-6 h. d Forest plot presenting the meta-analysis for VAS score-24 h.

Fig. 3

Forest plot presenting the meta-analysis for main outcomes of experimental group vs. control group. a Forest plot presenting the meta-analysis for analgesia requirement. b Forest plot presenting the meta-analysis for the time of first analgesic demand. c Forest plot presenting the meta-analysis for VAS score-6 h. d Forest plot presenting the meta-analysis for VAS score-24 h.

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The Time of First Analgesic Demand (h)

There were 4 RCTs [9,10,11,17] with 225 patients that reported the time of first analgesic. The other 2 RCTs [12,13] did not refer to the analgesic demand time. The results of meta-analysis using the random effects model indicated that the time of first analgesic demand was significantly longer in the experimental group than in the control group (WMD 2.19, 95% CI 0.98-3.41, p < 0.0004; fig. 3b).

VAS Score-6 h

Three studies [9,12,17] evaluated the VAS score in the postoperative period. But Lojanapiwat et al. [17] did not evaluate the pain status of patients at the 6th hour after the procedure. Pooling the data from the 2 studies [9,12] referred to VAS scores after 6 h showed no statistically significant difference between the experimental group and control group (WMD -1.79, 95% CI -3.64 to 0.05, p = 0.06; fig. 3c).

VAS Score-24 h

Two RCTs [9,12] including 104 patients reported the VAS score at 24th hour after the procedure. When pooled, the results showed that the VAS scores at 24 h after operation were significantly lower in the patients in the experimental group than in patients in the control group (WMD -0.54, 95% CI -0.77 to -0.31, p < 0.00001; fig. 3d).

Secondary Outcome

Hb Alteration

Pooling the data from the 2 studies [11,12] showed that there was no statistically significant difference in Hb alteration between the experimental group and the control group (WMD -0.06, 95% CI -0.16 to 0.05, p = 0.27; fig. 4a).

Fig. 4

Forest plot presenting the meta-analysis for secondary outcome of the experimental group vs. the control group. a Forest plot presenting the meta-analysis for Hb alteration. b Forest plot presenting the meta-analysis for operation time. c Forest plot presenting the meta-analysis for hospital stay.

Fig. 4

Forest plot presenting the meta-analysis for secondary outcome of the experimental group vs. the control group. a Forest plot presenting the meta-analysis for Hb alteration. b Forest plot presenting the meta-analysis for operation time. c Forest plot presenting the meta-analysis for hospital stay.

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Operation Time

Pooling the data from the 2 studies [11,17] showed that there was no statistically significant difference in operation time between the experimental group and the control group (WMD 5.28, 95% CI -4.41 to 14.97, p = 0.29; fig. 4b).

Hospital Stay

Pooling the data from the 2 studies [12,13] showed there was no statistically significant difference in hospital stay between the experimental group and the control group (WMD -1.02, 95% CI -7.84 to 5.80, p = 0.77; fig. 4c).

It is well known that most of pain during PCNL is caused by the dilatation of the renal capsule and parenchymal tract, as it is rich in pain-sensing nerves, and not because of the operation performed inside the renal system [18,19]. Furthermore, swing and movement of Amplatz sheath also lead to pain because of irritation to the diaphragm, pleura, or retroperitoneum [20]. Other factors, such as expansion of the skin, subcutaneous tissues, and muscles, are contributed to the pain after PCNL. A nephrostomy tube is also the principal element that caused patient discomfort and pain. Currently, there are various options including the use of kinds of analgesics, single-dose subarachnoid spinal anesthesia, and local infiltration of anesthetic agents [1,21,22]. But proper postoperative pain management with less-invasive techniques may be the main goal. One of the simple techniques for pain management is infiltration of the surgical site with local anesthetics.

Many researches in anesthesia have described the efficacy of local anesthetic infiltration in surgical incisions in surgery literature. A randomized trial by Bagul et al. [23] found that preincision infiltration with local anesthetic provided easy access and scores in analgesic control postoperatively in patients undergoing thyroid surgery with no effects on bruising or cosmesis. Rawal et al. [24] discovered that pain relief after ambulatory breast augmentation was superior with incisional patient-control regional analgesia under local anesthesia when compared to oral analgesic. And patient-control incisional regional analgesia was associated with few side-effects and less sleep disturbance [24]. In the urology study, Hsu et al. [25] demonstrated that varicocelectomy under local anesthesia was simple, effective, and a safe method with minimal complications. Recently, numerous studies have described local anesthetic used at the PNL site for postoperative pain management [10,11,12,13,17].

In a previous study, Haleblian et al. [26] reported no significant differences in patient-reported pain scores between the marcaine infiltration group and the saline infiltration group. However, a trend toward decreased postoperative analgesic requirements was observed in the marcaine infiltration group. Parikh et al. [21] evaluated the impact of infiltration of 20 ml bupivacaine 25% along the nephrostomy tube. The conclusion of this study was that peritubal infiltration of 0.25% bupivacaine reduces analgesic requirements and delayed the time of first request for demand analgesia after percutaneous nephrolithotomy (p < 0.05). Ugras et al. [9] reported that postoperative pain and analgesic requirements were decreased in combination of ropivacaine instillation with the metamizol group than the metamizol-alone group. And peak expiratory flow rate was also improved in combination of ropivacaine instillation with the metamizol group. Haleblian et al. [26] studied subcutaneous infiltration of 0.25% bupivacaine in 25 patients. They demonstrated that subcutaneous bupivacaine infiltration reduced postoperative analgesia requirement but no significant difference in VAS after PCNL. Our synthesized results showed that consumption of analgesic was less in the experimental group than in the control group during the postoperative period (WMD -25.32, 95% CI -48.09 to -2.55, p = 0.003). There was no significant difference between the mean VAS score in the experimental group than in the control group after 6 h, while it was significantly lower after 24 h in the patients who had received local anesthetic. The time of first analgesic demand was significantly longer in the experimental group (2.19, 95% CI 0.98-3.41, p < 0.0004). Decreased pain scores in the experimental group after 6 h may be due to the selective inhibition of afferent nociceptive sensitization pathways and delay in sensory recovery after motor recovery following local anesthetic infiltration around the nephrostomy tract [27]. There was no significant difference in the operation time, Hb alteration, and hospital stay between both groups (p > 0.05).

There were some limitations to this study. First, the sample size of studies included was relatively small and consequently, the results of our study were not very stable and reliable. Second, different types of local anesthetic infiltration (mentioned in table) could not be compared due to the small number of RCTs. Third, publication bias should also not be ignored because small studies with null results tend not to be published.

Our study indicated that local anesthetic infiltration around the nephrostomy tract had similar efficacy to the control group (no local anesthetic infiltration group) in terms of operation time, Hb alteration, and hospital stay, but offers some potential advantages over the control group (no local anesthetic infiltration group) in terms of analgesia requirement, the time of first analgesic demand, and VAS-24 (VAS score at 24th hour after the procedure). We believe that local anesthetic infiltration around the nephrostomy tract may prove a better alternative for postoperative pain management. However, good quality and large studies with long-term follow-up are warranted for further research.

None.

This work has not been presented anywhere else.

None.

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