After kidney stone surgery, non-opioid analgesia and a local anaesthetic block ranked best

Design

Bayesian network meta-analysis of randomised trials, PROSPERO registered

Population

45 trials with 2,626 adults undergoing percutaneous nephrolithotomy

Primary outcome

Postoperative pain (visual analogue scale) before and after 24 hours, plus complications

Effect

Levobupivacaine ranked above bupivacaine and ropivacaine; non-opioid analgesics superior; IV paracetamol plus local levobupivacaine ranked highest (effect sizes not given in the abstract)

A Bayesian network meta-analysis combined 45 randomised trials (2,626 patients) of postoperative pain control after percutaneous nephrolithotomy, with pain scores up to and after 24 hours. Interventions included nerve blocks and local anaesthetic infiltration, intravenous analgesics, local instillation, intrathecal anaesthesia and aromatherapy. The network showed no significant inconsistency or heterogeneity. It was registered in PROSPERO.

Levobupivacaine reduced pain scores more than bupivacaine or ropivacaine, given as an erector spinae plane block or local infiltration. NSAIDs and paracetamol showed superior efficacy, and opioids were effective early but not later. Intravenous paracetamol plus local levobupivacaine ranked highest in a multicriteria analysis, though the authors caution that the safety component rested on sparse, imprecise data, 21 studies had moderate bias, and renal impairment and obesity were poorly represented.

For a nephrology reader, the caveat that matters is NSAID use: the trials did not establish safety in patients with reduced kidney function, and NSAIDs are generally avoided in advanced chronic kidney disease. A multimodal plan with paracetamol and a regional block is the opioid-sparing option that is easier to defend in those patients.

• Consider a multimodal plan built on paracetamol and a local anaesthetic block for pain after nephrolithotomy
• Use NSAIDs cautiously or not at all in patients with reduced kidney function, a solitary kidney or bleeding risk
• Reserve opioids for breakthrough pain, with the lowest effective dose
• Agree the analgesia plan with the anaesthetic and urology teams before surgery
• Comparative safety could not be established from these data

Why it matters

Pain after percutaneous surgery delays recovery, and opioid-sparing plans are now routine in other specialties.

Don't overread it

Complication data were sparse and imprecise, so the ranking reflects pain relief and cannot establish comparative safety, particularly in patients with kidney impairment.

The statistics, in plain English

A network meta-analysis uses direct and indirect comparisons to rank many treatments at once, but a ranking depends on the quality of each trial and on how few head-to-head comparisons exist. Highest ranked does not mean significantly better than the next, and the rankings for safety here were weak.

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