What's the next step for a 42-year-old woman with severe left back pain, refractory to ketorolac (Nonsteroidal Anti-Inflammatory Drug (NSAID)) and opioids, 2 days after left laparoscopic radical nephrectomy for a 10cm renal mass, with stable vital signs and normal hemoglobin?

Management of Severe Left Back Pain After Laparoscopic Radical Nephrectomy

Immediate CT scan of the abdomen and pelvis should be performed to evaluate for postoperative complications such as retroperitoneal hematoma, urinoma, or abscess in this patient with severe pain refractory to standard analgesics.

Clinical Assessment

• The severe left back pain that is 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
• While stable vital signs and normal hemoglobin are reassuring against major hemorrhage, they do not rule out other significant complications 1
• Pain out of proportion to expected postoperative course is a red flag that warrants immediate investigation 1

Diagnostic Approach

• CT scan with contrast (if renal function permits) is the gold standard imaging modality to evaluate for:
  • Retroperitoneal hematoma
  • Urinoma
  • Abscess formation
  • Other surgical complications 1
• Laboratory studies should include:
  • Complete blood count to monitor for trending hemoglobin
  • Comprehensive metabolic panel to assess renal function
  • Urinalysis to evaluate for infection 1

Pain Management Considerations

• Multimodal pain management is recommended for postoperative pain control 1
• NSAIDs like ketorolac should be used with caution in patients with:
  • Preexisting renal insufficiency
  • Risk of bleeding
  • History of GI ulcers 1
• In post-nephrectomy patients specifically, ketorolac has been shown to be effective and safe when used appropriately 2, 3, 4
• For refractory pain, consider:
  • Neuraxial analgesia if not contraindicated
  • Consultation with acute pain service
  • Adjustment of current analgesic regimen 1

Management Algorithm

1. Immediate imaging: CT scan of abdomen and pelvis with contrast (if renal function allows) 1

2. Based on CT findings:

   • If retroperitoneal hematoma: Assess size and stability; may require surgical intervention if expanding or causing significant symptoms 1
   • If urinoma: Consider placement of percutaneous drain 1
   • If abscess: Drainage and appropriate antibiotics 1
   • If normal: Consider other causes of pain and adjust pain management strategy 1

3. Pain management while awaiting diagnosis:

   • Consider gabapentinoids for neuropathic component of pain 1
   • Consider regional anesthetic techniques if no contraindications 1
   • Optimize acetaminophen dosing (up to 4g/day if normal liver function) 1

Potential Complications After Laparoscopic Nephrectomy

• Bleeding complications occur in approximately 0.6-1% of cases 5
• Chylous ascites has been reported in approximately 0.6% of cases 5
• Rhabdomyolysis is a rare but serious complication 5
• Postoperative pain requiring extended hospitalization occurs in a small percentage of patients 3, 4

Pitfalls to Avoid

• Do not attribute severe, refractory pain to "normal" postoperative course without appropriate investigation 1
• Do not continue to escalate opioids without identifying the underlying cause of pain 1
• Do not administer NSAIDs in patients with significant renal dysfunction, as they can worsen renal outcomes 1, 6
• Do not delay imaging when pain is out of proportion to expected postoperative course, even with stable vital signs 1