Does a Hysterectomy Hurt? Comparing Narcotic Requirements and Pain Scores in Patients Undergoing Apical Prolapse Repair With or Without Hysterectomy : Urogynecology

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Does a Hysterectomy Hurt? Comparing Narcotic Requirements and Pain Scores in Patients Undergoing Apical Prolapse Repair With or Without Hysterectomy

Gillingham, Akira MD; Kenton, Kimberly MD, MS; Geynisman-Tan, Julia MD; Brown, Oluwateniola MD; Collins, Sarah A. MD; Lewicky-Gaupp, Christina MD; Mueller, Margaret G. MD

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Female Pelvic Medicine & Reconstructive Surgery 27(6):p 356-359, June 2021. | DOI: 10.1097/SPV.0000000000000860
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Abstract

The Centers for Disease Control and Prevention estimated that more than 60,000 Americans died by drug overdose in 2016, with 66% of these deaths involving a prescribed or illicitly obtained opioid.1 The overall death rate from drug overdose continues to increase annually, including the prescription opioid–related death rate, which increased 10.6% from 2015 to 2016.1 In the postoperative setting, prescribing narcotic pain medication to opiate-naive patients was found to increase their risk of chronic opioid use.2,3 Given the ongoing opioid epidemic, this highlights the dangers of overprescribing and overusing narcotic pain medications in the postoperative period.

In recent years, gynecologists and pelvic surgeons have adopted enhanced recovery after surgery (ERAS) protocols that expedite patient recovery after surgery and improve perioperative outcomes.4–6 A key component of ERAS protocols is optimization of pain control through premedication and opioid-sparing multimodal analgesia regimens. Preoperative counseling and patient education are also key elements of ERAS and help set patient expectations for postoperative pain control.

In 2016, our urogynecology division implemented a multidisciplinary ERAS protocol that includes guidelines for preoperative, intraoperative, and postoperative management of all of our surgical patients. In the preoperative period, patients are allowed to consume solid foods and clear liquids up to 6 and 2 hours before surgery, respectively, and are instructed on preoperative carbohydrate loading with Gatorade 2 hours before arrival to the hospital. Patients also receive preoperative pain control with ibuprofen 600 mg and acetaminophen 1000 mg upon arrival to the hospital. Intraoperative management includes opioid sparing anesthetic options (intravenous [IV] lidocaine, ketamine, acetaminophen, and ketorolac), as well as maintenance of euvolemia and normothermia. In the postoperative period, multimodal analgesia is provided with scheduled acetaminophen and ibuprofen, Opioids are only administered on an as-needed basis.

When counseling patients on expectations regarding postoperative pain control and same-day hospital discharge, a common concern expressed by patients undergoing prolapse repair with a concomitant hysterectomy was that the hysterectomy would induce significant pain in addition to the prolapse repair. This perception led to patients requesting a larger number of narcotic pills for pain control in the postoperative period and may have influenced a patient’s decision to undergo a uterine-sparing apical suspension procedure.

The objective of this study is to compare narcotic requirements with early postoperative pain scores in women undergoing apical prolapse surgery with and without concomitant hysterectomy. We hypothesized that hysterectomies were not associated with additional pain and conducted a retrospective analysis of our surgical cases to determine whether concomitant hysterectomy at the time of apical prolapse repair surgery affects PACU pain scores and intraoperative and PACU narcotic use.

METHODS

This is a retrospective cohort of patients undergoing apical prolapse repair at a single institution. After obtaining institutional review board approval, we identified all cases of apical prolapse repair in 2016 performed after the initiation of the ERAS protocol by 4 board-certified female pelvic medicine and reconstructive surgery physicians. All cases were performed under the ERAS protocol and were identified by current procedural terminology (CPT) code and included sacrocolpopexy (abdominal, CPT 57280; laparoscopic, CPT 57425), uterosacral ligament suspension (CPT 57283), sacrospinous ligament suspension (CPT 57282), and colpocleisis (CPT 57120) procedures.

Laparoscopic and robot-assisted sacrocolpopexies were analyzed in the laparoscopic cohort. Uterosacral ligament suspension, sacrospinous ligament suspension, and colpocleisis were analyzed in the vaginal cohort. Cases were excluded if the primary indication for surgery was not pelvic organ prolapse.

The following information was abstracted from the health record: demographics, medical comorbidities, procedure details, intraoperative complications, length of stay, baseline and postoperative care unit (PACU) pain scores, and operating room (OR) and PACU narcotic doses. Pain scores were obtained by PACU nurses using a visual analog scale (VAS), with scores ranging 0 to 10. Operating room and PACU narcotic doses were converted to morphine milligram equivalents (MME) to allow comparison of opioid agents of different potencies. The MME of a given opioid is calculated by multiplying the dose of that opioid by its conversion factor (Fig. 1) and represents the equivalent dose in milligram of oral morphine, for example, 1 mg of oral oxycodone is equivalent to 1.5 mg of oral morphine.

F1
FIGURE 1:
Morphine milligram equivalent conversions for opioids. PO, per os.

Our primary outcome measures were PACU pain scores at 4 and 6 hours after surgery and narcotic doses administered in the OR and PACU. Data were analyzed in SPSS Version 24 (Chicago, IL) and reported as mean ± standard deviation (SD). Continuous variables were analyzed using independent samples t test for parametric variables, Mann-Whitney test for nonparametric variables, and categorical variables were analyzed using χ2 test of association. Correlations are reported using Pearson ρ. We first performed univariate analysis of apical prolapse repair through all routes of access, followed by subgroup analyses of hysterectomy versus no hysterectomy in the laparoscopic and vaginal cases separately. Variables with a P value of less than 0.05 on univariate analysis were included in a multivariable linear regression.

A post hoc power analysis was performed. Based on previous studies, using a minimal clinically important difference of 2 in VAS pain scores, we assumed a 4-hour pain score of 4 ± 2 in patients with a hysterectomy and pain score of 2 in patients without. We calculated that 16 patients per group would be required to detect this difference with an α value of 0.05 and power of 80%.

RESULTS

One hundred fifty-six (156) cases of apical prolapse repair were identified and included in this analysis. Participants were 59 ± 11 years of age, 78% white, and had a mean + SD body mass index of 27 ± 5 kg/m2. There were no reported cases of chronic opioid use. One hundred seventeen patients (75%) underwent laparoscopic/robotic apical suspension, 35 (22%) were vaginal, and 4 (3%) were abdominal. Of these 156, 35 (22%) were performed without concomitant hysterectomy, whereas 122 patients (78%) underwent concomitant hysterectomy: 93 (76%) laparoscopic, 25 (20%) vaginal, and 4 (4%) abdominal.

On univariate analysis, the hysterectomy group was younger (58 ± 11 vs 64 ± 12 years, P = 0.01) and had longer OR times (214 ± 66 vs 164 ± 70 minutes, P = 0.02). Otherwise, the 2 groups had similar demographics including baseline pain scores (0.2 ± 1.2 vs 0.4 ± 1.4, P = 0.39), rates of concomitant mid urethral sling procedures (62% vs 68%, P = 0.55), and rates of overnight admission (74% vs 79%, P = 0.66; Table 1).

TABLE 1 - Demographics
All Cases Hysterectomy (n = 122) No Hysterectomy (n = 34) P
Age, y 58 ± 11 64 ± 12 0.007*
White 92 (75%) 30 (88%) 0.16
Smoker 20 (16%) 2 (6%) 0.17
BMI, kg/m2 28 ± 6 27 ± 5 0.49
EBL, mL 120 ± 11 91 ± 91 0.16
OR time, min 214 ± 66 164 ± 70 0.001*
Concomitant sling 75 (62%) 23 (68%) 0.55
Baseline pain score 0.2 ± 1.2 0.4 ± 1.4 0.39
Overnight admission 90 (74%) 27 (79%) 0.66
Data are presented as mean ± SD or n (%).
*Statistical significance.
EBL, estimated blood loss.

Hysterectomy by any route was not associated with increased OR MMEs (29 ± 25 vs 22 ± 17, P = 0.22), PACU MMEs (13 ± 17 vs 13 ± 13, P = 0.54), 4-hour PACU pain scores (2.5 ± 2.2 vs 2.0 ± 2.0, P = 0.22), or 6-hour PACU pain scores (2.6 ± 2.2 vs 2.3 ± 2.2, P = 0.54; Table 2). After including age and OR time in a multivariable regression model, there remained no difference in OR MMEs (P = 0.38), PACU MMEs (P = 0.99), 4-hour pain scores (P = 0.20), and 6-hour pain scores (P = 0.60). Likewise, there was no difference in same-day discharge or overnight admission between women who did and did not have a concomitant hysterectomy. There was a mild inverse correlation of OR MME on PACU MME (Pearson ρ = −0.19, P = 0.018).

TABLE 2 - Pain Scores and MMEs in Patients With and Without Concomitant Hysterectomy by Route of Entry
All Cases Hysterectomy (n = 122) No Hysterectomy (n = 34) P
4-h PACU pain score 2.5 ± 2.2 2.0 ± 2.0 0.22
6-h PACU pain score 2.6 ± 2.2 2.3 ± 2.2 0.54
OR MME 29 ± 25 22 ± 17 0.14
PACU MME 13 ± 17 13 ± 19 0.96
Laparoscopic Apical Suspension Hysterectomy (n = 94) No Hysterectomy (n = 23) P
Age 57 ± 10 59 ± 9 0.4
OR time, min 232 ± 63 197 ± 52 0.02*
4-h PACU pain score 2.3 ± 2.0 2.1 ± 2.1 0.71
6-h PACU pain score 2.5 ± 2.1 2.6 ± 2.1 0.75
OR MME 30 ± 25 23 ± 19 0.23
PACU MME 12 ± 17 14 ± 17 0.59
Vaginal Apical Suspension Hysterectomy (n = 24) No Hysterectomy (n = 11) P
Age 64 ± 11 74 ± 11 0.01*
OR time, min 149 ± 30 96 ± 49 0.001*
4-h PACU pain score 2.7 ± 2.4 1.6 ± 1.9 0.21
6-h PACU pain score 3.0 ± 2.6 1.8 ± 2.3 0.18
OR MME 24 ± 23 20 ± 11 0.58
PACU MME 18 ± 20 11 ± 24 0.38
Data are presented as mean ± SD.
*Statistical significance.

We then performed a subgroup analysis comparing hysterectomy and no hysterectomy in the vaginal and laparoscopic groups, individually. On univariate analysis of the laparoscopic apical suspension group, OR time was longer in cases performed with hysterectomy compared with cases without hysterectomy (232 ± 63 minutes vs 197 ± 52 minutes, P = 0.02). However, controlling for this increased OR time using logistic regression, there were no differences in OR MMEs (30 ± 25 vs 23 ± 19, P = 0.23), PACU MMEs (12 ± 17 vs 14 ± 17, P = 0.59), or 4-hour (2.3 ± 2.0 vs 2.1 ± 2.1, P = 0.71), and 6-hour postoperative pain scores (2.5 ± 2.1 vs 2.6 ± 2.1, P = 0.75) in patients who underwent laparoscopic apical suspension with and without hysterectomy.

On univariate analysis of the group performed vaginally, hysterectomy was associated with younger age (64 ± 11 vs 74 ± 11 years, P = 0.01) and longer OR time (149 ± 30 minutes vs 96 ± 49 minutes, P = 0.001). However, when controlling for age and OR time in a multivariable logistic regression, there were again no differences in OR MMEs (24 ± 23 vs 20 ± 11, P = 0.58), PACU MMEs (18 ± 20 vs 11 ± 24, P = 0.38), or 4-hour (2.7 ± 2.4 vs 1.6 ± 1.9, P = 0.21) and 6-hour postoperative pain scores (3.0 ± 2.6 vs 1.8 ± 2.3, P = 0.18) in patients with and without hysterectomy.

DISCUSSION

Our study demonstrates that women undergoing concomitant hysterectomy at the time of apical prolapse surgery, irrespective of route of access, do not experience more pain than those undergoing apical prolapse repair alone. Patient expectations are an increasingly important in surgery, and women often think that the addition of a hysterectomy will impact their postoperative course at the time of prolapse repair. Our data suggest that immediate postoperative pain after prolapse surgery is not impacted by concomitant hysterectomy. Although we did not examine pain scores in our patients after hospital discharge, prior studies have found a positive correlation between elevated pain scores 4 hours after hysterectomy (laparoscopic and vaginal) and the development of persistent pain at 6 months.7

In all patients undergoing apical prolapse surgery using an ERAS protocol, we found that patient-reported pain scores were low (between 2 and 3 on a 10-point VAS scale) at both 4 and 6 hours postoperatively, and there was no difference between pain scores in women who did or did not undergo concomitant hysterectomy. Similarly, women who underwent concomitant hysterectomy did not use more MMEs than those who underwent apical suspension alone. The mean OR MME in the hysterectomy group was 29, equivalent to 1.45 mg of IV hydromorphone, and in the no hysterectomy group, it was 22, equivalent to 1.1 mg of IV hydromorphone. The mean PACU MME use in both groups was 13, equivalent to 0.65 mg of IV hydromorphone or 8.6 mg of oxycodone. A retrospective analysis by Modesitt et al8 reported similarly low pain scores and postoperative narcotic use in patients undergoing minimally invasive gynecologic surgery using an ERAS protocol. Given that patient education is an important aspect of ERAS protocols, the findings of this study can be used to counsel patients that pain and narcotic requirements are not affected by the addition of a concomitant hysterectomy. Patients undergoing an apical suspension procedure by any route with concomitant hysterectomy can expect a similar PACU recovery to those patients who have had a previous hysterectomy.

Not surprisingly, the addition of a concomitant hysterectomy increased OR time. However, concomitant hysterectomy did not increase estimated blood loss or rates of overnight admission. The rate of 23-hour observation after is higher than that reported at other centers and in other studies,9 which is attributable to a change in practice during implementation of ERAS; in 2016, our institution had not yet adopted same-day discharge for ERAS cases. In comparison, in 2018, our same-day discharge rate is 92% for these cases.

This study is strengthened by the large number of laparoscopic/robotic and vaginal cases in our cohort, which allowed for the evaluation of pain scores and narcotic requirements in both routes of surgery. Limitations of this study include its retrospective design and short follow-up period (up to 6 hours in the PACU), which do not allow us to comment on the effect of concomitant hysterectomy on long-term pain scores or narcotic requirements later in the postoperative period. Nevertheless, our study demonstrates that a concomitant hysterectomy does not increase pain or narcotic use in the setting of minimally invasive prolapse repair by any route in the immediate postoperative period.

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Keywords:

apical prolapse repair; hysterectomy; postoperative pain scores; narcotic use

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