Bridging evidence gaps in opioid-sparing postoperative pain control for percutaneous nephrolithotomy: a network meta-analysis identifying optimal strategies.

In 30 seconds

This systematic review and Bayesian network meta-analysis compared postoperative analgesic strategies in adults undergoing percutaneous nephrolithotomy (PCNL), using randomised controlled trials that assessed pain. The network included 45 trials and 2,626 patients. Levobupivacaine-based erector spinae plane blocks or local infiltration reduced pain more than bupivacaine or ropivacaine at both under 24 hours and 24 hours or later. Non-opioid analgesics, including NSAIDs and paracetamol, showed better efficacy overall; opioids performed better only in the short term. Intravenous paracetamol plus local-infiltration levobupivacaine ranked highest in the benefit-risk analysis, but safety estimates were uncertain.

Key findings

• The network meta-analysis included 45 randomised trials and 2,626 adults undergoing PCNL.
• Levobupivacaine outperformed bupivacaine and ropivacaine for pain reduction both under 24 hours and at 24 hours or later.
• NSAIDs and paracetamol showed superior efficacy overall, whereas opioids performed better only for short-term pain.
• Intravenous paracetamol plus local-infiltration levobupivacaine ranked highest in multicriteria analysis; comparative safety remained uncertain.

Why it matters

PCNL can cause substantial postoperative pain, and opioid exposure carries risks. These comparative findings suggest that multimodal regimens using non-opioid analgesics and levobupivacaine may provide effective pain control while limiting reliance on opioids. However, the ranking should not be read as proof of superior safety: complication data were sparse and imprecise, and the evidence varied in quality.

What to keep in mind

Pain-assessment protocols varied, 21 studies had moderate risk of bias, and high-risk subgroups were poorly represented. Sparse, imprecise complication data prevented reliable comparative safety conclusions.