OPIOID-FREE ANESTHESIA AND LONG-TERM RECOVERY AFTER PERCUTANEOUS NEPHROLITHOTOMY: A SYSTEMATIC REVIEW

Abstract

Background: Percutaneous nephrolithotomy (PCNL) is associated with postoperative pain and perioperative opioid exposure. Opioid-free anesthesia (OFA) has emerged as a potential strategy to reduce opioid-related adverse effects and improve postoperative recovery. However, evidence specifically evaluating OFA in PCNL remains limited. Objective:To systematically review the available evidence regarding opioid-free and opioid-sparing anesthetic and analgesic strategies in patients undergoing PCNL, with particular emphasis on postoperative pain, opioid consumption, quality of recovery, and longer-term recovery outcomes. Methodology:Systematic literature search was done in PubMed/MEDLINE, Embase, Scopus and Web of Science. The studies that assessed OFA, opioid-sparing regional anesthesia, multimodal analgesia, or opioid-free postoperative pathway in patients undergoing PCNL were evaluated. The anesthetic technique, opioid exposure, postoperative pain, opioid use, rescue analgesia, recovery, hospital stay, and long-term outcome data were retrieved. Findings were synthesized narratively, as there was significant heterogeneity in interventions and outcome measures. Results:The literature available for PCNL showed consistent evidence of opioid-sparing regional blocks (ESPB and QLB) with a decrease in postoperative opioid usage, pain scores, and requirement for rescue analgesics. Other studies also reported faster ambulation, better patient satisfaction and shorter hospital stay. Most PCNL studies have, however, used intraoperative opioids and thus did not truly represent OFA. Opioid-free postoperative pathways were also promising, with reports of decreased opioid prescribing and opioid-free discharge in certain patients. However, the real-time intraoperative OFA during PCNL and its impact on long-term outcomes were poorly studied. Conclusion:There is current evidence in support of multimodal and regional opioid-sparing approaches to minimize opioid exposure after PCNL. However, there is a lack of evidence specific to PCNL that demonstrates that true OFA will have better short or long term recovery than conventional opioid-based anesthesia. Long-term studies with standardized OFA protocols and longer follow-up are required to assess long-term opioid use, quality of life, and functional recovery in well-designed randomized trials.