Design: Single-centre randomised controlled trial
Population: 149 men having robot-assisted radical prostatectomy with quadratus lumborum block
Primary outcome: 24-hour oxycodone consumption via PCA
Effect: Median 12.0 vs 19.0 mg; location shift -6.0 mg (95% CI -10.0 to -2.0)

A single-centre randomised trial allocated 149 men having robot-assisted radical prostatectomy to opioid-free anaesthesia with dexmedetomidine and ketamine or a remifentanil-based technique. Both groups had the same multimodal premedication, bilateral quadratus lumborum blocks, sevoflurane and oxycodone patient-controlled analgesia.

Oxycodone use over 24 hours was lower with opioid-free anaesthesia: median 12 mg against 19 mg, an estimated shift of 6 mg (95% CI 2 to 10). Pain scores did not differ at any time, nausea and vomiting were infrequent in both groups, and bradycardia, hypotension, creatinine and white-cell count did not differ.

A 6 mg reduction in oxycodone is modest and, with pain unchanged, its clinical importance is uncertain. The comparator was a remifentanil technique, which may itself raise later opioid needs.

For units that already use regional blocks and multimodal analgesia, the trial shows opioid-free anaesthesia is feasible in this operation without obvious haemodynamic cost. It is not evidence that it improves recovery.

Consider opioid-free anaesthesia for robotic prostatectomy when a regional block and multimodal analgesia are in place.
Expect a modest fall in postoperative opioid use, not a change in pain scores.
Monitor for bradycardia with dexmedetomidine, although rates did not differ here.
Do not expect a recovery benefit on this evidence alone.

Why it matters

It adds randomised evidence to a technique often adopted on enthusiasm, and shows the gain is modest when good regional analgesia is already used.

The statistics, in plain English

The 6 mg difference has an interval from 2 to 10 mg, so the reduction is likely real but small. Medians are used because opioid consumption was skewed by a few heavy users.