A Novel Sacral Erector Spinae Block Reduces Opioid Use After Gender-affirming Vaginoplasty

Abstract

ABSTRACT Introduction Surgeries that affirm a person's gender identity can be the ultimate end to the distress associated with the discordance between one's gender identity and sex assigned at birth. Gender-affirming vaginoplasty (GAV) is increasingly being performed as a critical component of gender transition for individuals assigned male at birth transitioning to female. As GAV becomes offered at more centers around the United States (US), it is important to understand and consider surgical outcomes that are unique to this operation without losing sight of the larger context of surgical care in the US. In this vain, it is known that post-surgery prescriptions for opioids are a catalyst for opioid addiction in nearly 1 in 16 surgery patients; furthermore, individuals with gender dysphoria are twice as likely to abuse prescription opioids. Regional anesthetic blocks have been adopted in many urologic surgeries to reduce opioid consumption both during and after surgery. The sacral erector spinae plane block (ESP) is a novel block that can block the S2-S4 pain levels in addition to some of the lumbar plexus with benefits over a neuraxial/epidural block including being a superficial block, no significant motor weakness, reduced risk of epidural hematoma, and less risk of intraoperative hemodynamic lability. Objective We sought to review complications and opioid usage after a novel sacral erector spinae plane block as an adjunct for pain control in the perioperative period in patients undergoing robotic-assisted penile inversion vaginoplasty. Methods We reviewed all charts of patients undergoing robotic-assisted penile inversion vaginoplasty or vulvoplasty at our institution. On the morning of surgery, patients were placed in a prone position and administered midazolam and fentanyl for sedation. Median sacral crests and the erector spinae muscle/plane (ESP) were identified using ultrasound guidance, and 0.2% ropivacaine was injected at the S4 and S2 sacral crest. Results A total of 13 patients received the ESP block. There were no complications either in the immediate post-block period or after surgery related to the block. Mean opioid consumption in the first 24 hours after surgery, 24-48hr, 48-72hr, 72-96hr, and 96-120 hours after surgery were 29.1, 50.9, 46.0, 36.5, and 38.7 oral morphine equivalents (OMEs), respectively. There was a significantly reduced amount of OME consumption in the 24 hours after surgery compared to the 24-48 hour period (p=0.017). Conclusions Sacral erector spinae plane block is a safe and efficacious way to reduce opioid consumption in the postoperative period after gender-affirming robotic-assisted penile inversion vaginoplasty or vulvoplasty. Disclosure No