Management of Severe Left Back Pain After Laparoscopic Radical Nephrectomy

Clinical Assessment

The National Comprehensive Cancer Network recommends that severe left back pain refractory to ketorolac and opioids two days after laparoscopic radical nephrectomy requires prompt evaluation, as this is not typical for the expected postoperative course 1, 2
Stable vital signs and normal hemoglobin are reassuring against major hemorrhage, but do not rule out other significant complications, according to the National Comprehensive Cancer Network 1
Pain out of proportion to expected postoperative course is a red flag that warrants immediate investigation, as stated by the National Comprehensive Cancer Network 2

The National Comprehensive Cancer Network recommends CT scan with contrast as the gold standard imaging modality to evaluate for retroperitoneal hematoma 3, urinoma 2, abscess formation 4, and other surgical complications 1, 2
Laboratory studies should include complete blood count to monitor for trending hemoglobin 5, comprehensive metabolic panel to assess renal function 1, and urinalysis to evaluate for infection 1

Multimodal pain management is recommended for postoperative pain control, according to the World Journal of Emergency Surgery and World of Neurosurgery 6, 3
NSAIDs like ketorolac should be used with caution in patients with preexisting renal insufficiency 4, risk of bleeding 5, or history of GI ulcers 3, 5, 4
For refractory pain, consider neuraxial analgesia if not contraindicated 5, consultation with acute pain service 5, or adjustment of current analgesic regimen 5

Immediate imaging with CT scan of abdomen and pelvis with contrast is recommended, as stated by the National Comprehensive Cancer Network 1, 2
Based on CT findings, consider surgical intervention for retroperitoneal hematoma 1, placement of percutaneous drain for urinoma 2, drainage and antibiotics for abscess 2, or adjustment of pain management strategy if normal 6, 5

Do not attribute severe, refractory pain to "normal" postoperative course without appropriate investigation, as warned by the National Comprehensive Cancer Network 1, 2
Do not continue to escalate opioids without identifying the underlying cause of pain, according to the World of Neurosurgery and World Journal of Emergency Surgery 3, 5
Do not administer NSAIDs in patients with significant renal dysfunction, as they can worsen renal outcomes, as stated by the World of Neurosurgery 4
Do not delay imaging when pain is out of proportion to expected postoperative course, even with stable vital signs, as recommended by the National Comprehensive Cancer Network 1, 2