Penile Block Research Articles

Comparative study between intrathecal fentanyl and dorsal penile nerve block for controlling postoperative pain after inflatable penile prosthesis implanation

Objectives: To compare the efficacy of intrathecal fentanyl and dorsal penile nerve block for postoperative pain management in patients undergoing inflatable penile prosthesis (IPP). Patients and methods: A prospective single-center study included 80 patients amenable to IPP. Patients were divided equally into two groups. Group I included 40 patients who were managed with spinal anesthesia with intrathecal fentanyl before undergoing IPP. Group II comprised 40 patients who received spinal anesthesia with dorsal penile block before IPP. Study groups were compared regarding postoperative VAS (Visual Analog Scale) scores, total narcotics consumption, patient satisfaction levels, and perioperative complications. Results: The study groups were comparable regarding baseline patients’ criteria. The operative time was comparable between the study groups, with group I and group II having respective median times of 64 minutes (interquartile range: 55-78) and 67 minutes (interquartile range: 56-81) (p = 0.65). Additionally, both groups demonstrated similar distributions in IPP implant cylinder and reservoir size (p = 0.9). Postoperative pain was higher in group I, with a statistically significant difference (p < 0.001). Eight patients in group I (20%) called the physician’s office asking for pain medication, compared to two patients in group II (5%) (p = 0.04). 85% of patients in group II were highly satisfied compared to 50 % in group I (p = 0.003). We reported a 5% complication rate in group I compared to 2.5% in group II (p = 0.6). Conclusions: The present study found that the dorsal penile nerve block offers superior postoperative pain control and patient satisfaction compared to intrathecal fentanyl for patients undergoing inflatable penile prosthesis insertion.

Comparison of penile block using the reverse US-guided nerve block or landmark guidance during circumcision in pediatric population: a retrospective study

Comparison of penile block using the reverse US-guided nerve block or landmark guidance during circumcision in pediatric population: a retrospective study

Glans ischaemia after circumcision in adult males: A two-patient case series and a narrative review of the literature.

Glans necrosis after circumcision is an exceedingly rare complication among adult males, with only a handful of cases being reported in the literature. We present here two cases of glans ischaemia observations after circumcision in both a 19-year-old and a 26-year-old patient; both were managed with oral medications in the outpatient setting, with complete restitutio-ad-integrum. A narrative review of the literature was also performed to better describe the possible predisposing factors; the treatment/management options; and the typical outcomes among the adult males experiencing with this complication. Penile dorsal anaesthetic blocks, monopolar cautery usage and compressive wound dressing are all reported to play a role as co-factors for glans ischaemia after circumcision, hence their adoption should be mindful. There is no consensus on the management of ischaemia of the glans after male circumcision. The favourable outcomes being reported for most of the literature cases of glans ischaemia after circumcision among adults despite the adoption of diverse empirical therapeutic strategies suggest that the role of the proactive management may be questionable.

Comparison of Post-Operative Analgesia of Caudal versus Dorsal Penile Nerve Blocks for Pediatric Patients Undergoing Hypospadias Repair

Abstract Background Hypospadias is the second most common congenital disorder in males after cryptorchidism, but it is the most common penile congenital malformation. It is an abnormality of anterior urethral and penile development in which the urethral opening is ectopically located on the ventral aspect of the penis proximal to the tip of the glans penis, which, in this condition, is splayed open. The urethral opening may be located as far down as in the scrotum or perineum. The penis is more likely to have associated ventral shortening and curvature, called chordee, with more proximal urethral defects. Aim of the Work The aim of this study is to compare the effectiveness of penile block versus caudal block using bupivacaine on the quality of analgesia after hypospadias repair in pediatrics. Methodology This prospective randomized comparative clinical study was conducted in Ain Shams University Hospitals; Pediatric Surgery Unit. It included 30 male patient aged (1–8) years, ASA I or II patients undergoing hypospadias (distal penile and mid penile) repair. They were divided into two groups: Group P: Penile block (n = 15) received dorsal penile nerve block by using the subpubic approach technique. Group C: Caudal block (n = 15) received caudal epidural block using a 22-G needle in the lateral decubitus position. Results There was statistically high significant difference between the two groups in postoperative MAP and HR (p value <0.001) but no statistically significant difference between them in Spo2. FLACC pain scores were significantly lower in group C compared with group P at PACU and 3 hours postoperative (p value <0.001) but no statistically significant difference between them at 6, 9 and 12 hours postoperative. Also, The time for first rescue analgesia was significantly longer in caudal group compared with penile group (P < 0.001) and the total analgesia consumption was also significantly lower (P < 0.001) in group C compared with group P. Postoperative time of ambulation was significantly lower (P < 0.001) in group P compared with group C. Conclusion The current study revealed that Caudal block provided significantly prolonged postoperative analgesia, reduced the postoperative analgesic requirements and prolonged time of ambulation as compared with Penile block in pediatric patients undergoing hypospadias repair.

(188) Horizontal Plication and Reduction Corporoplasty for Penile Girth Discrepancy (Christmas Tree Deformity)

Abstract Introduction We present a case of severe Peyronie's Disease, described as the “Christmas tree deformity” due to its crescendo shaped proximal girth discrepancy. This very rare deformity and proposed surgical correction technique have only been described in the literature once beforehand. Objective To depict the surgical correction of the severe penile girth discrepancy in video format. Methods At the start of the case, artificial erection was performed, revealing significant girth discrepancy. The proximal base of the shaft measured 21.5 cm, mid shaft 18.5 cm, and distal shaft 12 cm (Image 1). A circumcising incision was made and a plane along Buck’s fascia developed. Using careful blunt and sharp dissection, left and right neurovascular bundles were carefully elevated and gently lifted to the midline to allow for plication suture placement laterally. An artificial erection was again created, revealing significant asymmetry with 9.5cm girth discrepancy between proximal and distal shaft. Plication sutures of 1-0 Ethibond were placed using a “1+1=2” dot horizontal plication pattern, starting at the base and progressing to mid shaft on both the left and right sides. Plication sutures were placed systematically until symmetric girth was confirmed using artificial erection. A TachoSil graft was then placed along the shaft to decrease likelihood patient would feel the numerous Ethibond sutures below and also improve hemostasis. Dartos fascia was then closed with a Vicryl suture and the circumcising incision closed in a running subcuticular fashion. Again, artificial erection showed drastic improvement in penile girth magnitude and symmetry. A penile block was performed and the penis was wrapped in Kerlix gauze and coban. Results The patient was discharged on the same-day of surgery with oral pain medications. He was seen back in follow-up at 8 weeks postoperatively at which time he endorsed an uneventful recovery and that he was once again able to have penetrative intercourse with his partner. Conclusions We are proud to report on the second known case of horizontal plication and reduction corporoplasty for correction of severe penile girth discrepancy, “Christmas tree deformity.” Despite a lack of available literature on the deformity and surgical technique, we believe it is a safe and effective treatment option for patients with this rare form of Peyronie's. Disclosure No.

(040) Local Anesthesia Only for Penile and Scrotal Procedures: A Prospective Analysis of Patient Tolerability as an Alternative to Sedation

Abstract Introduction Traditionally, urological procedures utilize general or spinal anesthesia (GA) in an operating room (OR) to achieve adequate periprocedural pain relief. However, this approach presents various obstacles, including high OR related expenses, difficulties in accessing healthcare in rural areas, higher risk of anesthetic related complications and long wait times for patients due to limited OR space. This is particularly evident in penile and scrotal procedures, which often receive non-urgent treatment and result in wait times exceeding six months in Canada. The use of local anesthesia (LA) only is an appealing approach that has been gaining more traction in recent literature – however, no study to date has evaluated patient-reported tolerability to procedures conducted in this manner. Objective To investigate the surgical outcomes and patient-reported tolerability of penile and scrotal urologic procedures performed solely under LA. Additionally, information regarding complications is collected to provide data regarding the safety of this method, offering a viable alternative without the need for sedation. Methods This prospective study is registered as a clinical trial NCT05617261. Adult patients undergoing penile or scrotal surgery under LA only have been enrolled since August 2022, and is ongoing until August 2023. Procedures of interest include hydrocelectomies, spermatocelectomies, epididymectomies, testicular biopsies, circumcisions and frenulectomies. For scrotal procedures LA is administered along the median raphe along with a spermatic cord block, and for penile procedures a subcutaneous ring and dorsal penile block is utilized. Demographics, surgeon- and patient-reported visual analogue pain scores (VAS), and surgical variables are collected. Patient tolerability to the procedure and future anesthetic choice for a hypothetical repeat procedure are assessed at a follow-up appointment as our primary outcome. Complication data is also collected including recurrence (if applicable), emergency room visits, excess pain, hematoma & infection. Statistical tests include analyses to determine associations between demographic or surgical variables and patient-reported outcomes. Results Thus far, 215 patients are enrolled with complete follow-up data and statistical analysis on 72 patients. The mean age ± SD is 42.2 ± 16.4 years and there has been a 100% success rate with no perioperative complications or conversions to sedation or general anesthetic. Table 1 highlights the current patient demographic differences between those who do or do not recommend LA. Table 2 describes VAS at each point in time. On follow-up, 93.1% of patients indicated they would opt for LA for a hypothetical repeat procedure, with Figure 1 illustrating this by procedure type. Of the minority opting for GA, only 2 patients did so due to excess pain – highlighting that patient tolerability is not a limiting factor; instead, a desire to have no memory of the procedure is prevalent in this small cohort. Conclusions LA only is a promising technique for various scrotal and penile urologic procedures with high levels of patient tolerability. As we continue our analysis, we anticipate minimal complication rates similar to existing literature and data highlighting cost savings to our public health care system with a substantial reduction in patient wait times and surgical and recovery times – allowing for increased surgical efficiency and accessibility. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Boston Scientific.

The Effect of Penile Block Application on Pain Control in Cystoscopy

Cystoscopy is a very effective diagnostic and follow-up method used during many urological procedures. Although the pain has decreased with the frequent use of the flexible cystoscope recently, it is a really uncomfortable method for some patients. In this study, we aimed to investigate the effect of penile block application on pain control during cystoscopy. In this study, the files of 157 male patients who underwent rigid cystoscopy for various reasons between March 2017 and June 2019 were retrospectively scanned. The patients were divided into two groups; those who underwent penile block and those who did not. A visual analog scale was used in all patients to evaluate pain levels. Group I contained 87 and Group II contained 70 patients. The mean pain score in Group I was higher (4.40±0.782) than that in Group II (1.84±0.681) this difference was statistically significant (p=0.032). The use of urethral lidocaine along with penile block has been shown to minimize pain during cystoscopy and increase the tolerability of this procedure.

Analgesia for Infant Circumcision: Eutectic Mixture of Local Anesthetic (EMLA) Cream versus Dorsal Penile Nerve Block using Bupivacaine

Context: Circumcision is a painful procedure; thus, analgesia for neonatal circumcision is advocated for every male infant, and its use is considered essential by the American Academy of Pediatrics. Aim: This study aimed to compare the analgesic, hemodynamic effects, and complications of an eutectic mixture of a local anesthetic cream versus dorsal penile nerve block using bupivacaine for infants coming for circumcision. Materials and Methods: This was a prospective randomized interventional study involving 64 infants scheduled for circumcision at the Jos University Teaching Hospital. Infants were randomized into one of two groups through allocation concealment technique. Group I received dorsal penile nerve block with plain bupivacaine 0.5 mL/kg of 0.25%, while group II received 1 g of an eutectic mixture of a local anesthetic cream (EMLA). Circumcision started 5 minutes after penile block for group I and 1 hour after EMLA cream application for group II. Pain levels using CRIES scale, hemodynamic parameters, duration of surgery, and postoperative complications were noted and documented. Data were analyzed using SPSS version 23. A P value of less the 0.05 was considered statistically significant. Results: The study groups were comparable in demographic characteristics (P = 0.054). Less infants had CRIES scores of >4 in the DPNB group up to 2 hours postoperative period. Hemodynamic parameters were within normal ranges but higher in the EMLA group. No complication was noted in both study groups. Conclusion: Dorsal penile nerve block with bupivacaine provided better analgesia in infants undergoing circumcision than EMLA.

Comparison of postoperative analgesic efficacy of bupivacaine and levobupivacaine for dorsal penile block

Comparison of postoperative analgesic efficacy of bupivacaine and levobupivacaine for dorsal penile block

Efficacy of adjuvant dexmedetomidine on penile block for pediatric hypospadias repair

The management of postoperative pain, particularly in younger children, presents a challenge due to their limited ability to articulate the intensity of pain, lower pain threshold, and restricted availability of approved analgesics for pediatric use. Peripheral nerve blocks may be favored over neuraxial blocks because they allow quicker mobilization after surgery. The present study aims to investigate the potential impact of adding dexmedetomidine to a local anesthetic (bupivacaine) on the analgesic efficacy in dorsal penile nerve block in hypospadias repair surgery. In this prospective double-blinded clinical trial, 50 children aged between 6 months and 6 years old undergoing hypospadias repair surgery participated. Analgesia was administered through a dorsal penile nerve block (DPNB) at the end of surgery. Participants were divided into two groups; one received bupivacaine alone, and the other received dexmedetomidine and bupivacaine in DPNB. Pain and sedation levels were assessed with FLACC score and MOAA/S score, respectively, at 0,1,2 and 4h after surgery. Vital signs and adverse effects were also recorded, including hemodynamic changes, nausea, and vomiting. There was no statistically significant difference in demographic variables. As illustrated in Figure, the median of FLACC score in group BD was significantly lower compared to group B at every measured time point. MOAA/S score was significantly lower in group BD than in group B (p<0.001), indicating a higher sedation level. None of the participants in either group experienced any adverse effect except for vomiting, which was not statistically significant (8% in group B vs. 4% in group BD, p>0.999). Several studies have documented the supplementary analgesic properties of dexmedetomidine when used in conjunction with local anesthetic during various surgical procedures and nerve blocks. The present study provides evidence for the additional analgesic efficacy of dexmedetomidine and bupivacaine in the context of dorsal penile nerve block during hypospadias repair surgery while not yielding any significant adverse outcomes. Although the patients in our study were monitored for 4h in the postanesthesia care unit (PACU), conducting a more comprehensive assessment of patients is advisable. The findings of our study indicate that incorporating dexmedetomidine alongside bupivacaine in dorsal penile nerve block during hypospadias repair surgery may lead to enhanced management of postoperative pain. The lack of adverse effects implies it may be a potentially safe supplementary pain reliever for surgical procedures.

Analgesic effect of sacral erector spinae, penile and caudal block after hypospadias surgery: A randomized single blind controlled trial

ABSTRACT Background Hypospadias surgery is associated with acute postoperative pain needing long-term analgesia. Regional anaesthesia is commonly used with general anaesthesia (GA). We aim to compare sacral erector spinae plane block (ESPB) caudal and penile blocks in pain management following hypospadias surgery. Patients and methods This randomized controlled single blind trial was established on 132 pediatric cases aged from 1 to 5 years, American Society of Anesthesiologists (ASA) physical status I-II, planned for hypospadias surgery. Cases were classified into three equal groups; group C: received caudal block (CB) (1 ml/kg bupivacaine 0.25%, maximum 20 ml), group P: received penile block (0.1 ml/kg bupivacaine 0.5%, maximum 2.5 ml) and finally, group E: received ultrasound guided sacral bilateral ESPB (1 mL/kg 0.25% bupivacaine, maximum 20 ml). The blocks were done after GA induction and before the surgical incision. Results Time to 1st rescue analgesia was significantly delayed in groups C and E than group P (P < 0.001) and was insignificantly different between groups C and E. Total pethidine consumption was significantly lower in groups C and E than group P (P = 0.003, and 0.028, respectively). FLACC scores were significantly lower in groups C and E than group P at 4, 6, 8 and 12 h (p < 0.05) and were insignificantly different between groups C and E. Penile engorgement was insignificantly different among the three groups. Conclusion Both ESPB and CB had better pain control and lower opioid consumption compared to penile block, but CB is associated with incidence with penile engorgement and hypotensiveness than other techniques.

(348) Implementation of Opioid- Free and Opioid-Reduced Protocols for Postoperative Pain Management After Penile Prosthesis Surgery

Abstract Introduction Postoperative pain management after (PP) penile prosthesis is challenging and it has traditionally required opioid medication. In light of the ongoing nationwide opiate epidemic and in an effort to reduce the risk of postoperative opioid dependence, urologic prosthetic surgeons have sought to establish opioid-free and/or opioid-reduced protocols (OFP, ORP respectively) for PP postoperative pain management. Objective This study seeks to investigate the patterns of adoption of OFP or ORP among surgeons who perform PP surgery and potential barriers to their implementation. Methods A 13-question confidential survey was sent to members of the Sexual Medicine Society of North America (SMSNA) via email. The survey was administered via Qualtrics. T-test was used to analyze survey responses. Results 43 urologists responded to the survey, with representation from every American Urologic Association geographic section. Most respondents (73.18%) performed penoscrotal PP and 43% of respondents performed more than 30 PP per year. OFP was used most of the time by 24.39% of respondents and ORP was used most of the time by 73.18%. No significant relationship was found between the use of an OFP/ORP and geographical region, number of implants performed per year, surgical approach, or location of reservoir placement. Of the respondents using an ORP, 100% prescribed 10 doses of opioid medication or less upon discharge. 41.51% of respondents used an OFP/ORP from published literature and 9.43% consulted their local anesthesia or pain management department. The most commonly used modalities of non-opioid analgesia were: non-steroidal anti-inflammatories (95.1%), acetaminophen (87.8%), dorsal penile block (80.4%), gabapentin (46.3%), and pudendal block (43.9%). Following initiation of an ORP/OFP, 9.3% reported an increase in phone calls and 11.6% reported an increase in refill requests. There were no reports of increased patient dissatisfaction. Most respondents (65.8%) were extremely satisfied with their protocols. Conclusions OFP/ORP after PP surgery appear to be widely adopted by the urologic prosthetic community without a significant increase in patient or surgeon dissatisfaction. Disclosure Any of the authors act as a consultant, employee or shareholder of an industry for: Coloplast (ASB).

(377) Optimization of the Medical Protocol for the Treatment of Peyronie's Disease

Abstract Introduction Peyronie's disease is a widespread and potentially disabling condition affecting patients’ quality of life. Practitioners and researchers should explore the different approaches proposed to optimize management and tailor it to the patient. Objective To evaluate the efficacy and reproducibility of a semi-invasive protocol for Peyronie's disease made of "optimized" platelet-rich plasma (PRP) injections + penile traction + Phosphodiesterase type 5 (PDE5) inhibitors. Methods The study selected 12 patients who presented with the typical symptomatology of Peyronie's disease for less than 18 months with a curvature of less than 60° and had not received any other medical therapy. The average age was 49 years. 8 patients had a single plaque while 4 had multiple locations. The protocol consisted of 6 sessions of PRP injection, associated with a stretching of the penis and a daily intake of 5mg of Tadalafil. The parameters collected before and after the protocol were: Angulation of the penis, pain Visual Analogue Scale (VAS) on intercourse, International Index of the erectile function-5items (IIEF5), plaque size on ultrasound as well as the Peyronie Disease's Questionnaire scale (PDQ). Protocol description: - PRP injections: 6 injection sessions at one-week intervals. Each session is performed as follows: 1) Autologous collection of 10ml of blood which will be centrifuged at a force of 1500g RCF for 10min, only the supernatant plasma will be taken, avoiding the buffy coat which will only maintain an inflammatory reaction and will considerably reduce the activity of the PRP. 2) Performing a penile block with pure lidocaine 7ml on each side, avoiding peri-platelet injections which will lead to a significant decrease in platelet functionality. 3) Mechanical fragmentation of the plaques with an 18G or 25G needle depending on the sensitivity of the subject, after manual or ultrasound identification, is an essential time of the protocol conditioning the result. 4) Plasma injection around and inside fibrous plaque of the albuginea - Penile traction therapy (PTT): Throughout the protocol, the patient will stretch his penis for one hour, three times a day minimum. - Daily intake of 5mg of Tadalafil. Results The patients were well informed and followed the same protocol during the 6 weeks. The evaluation was done 3 months after the first injection: - Improvement in mean angulation: from 34° to 16°. - Significant decrease in pain during intercourse: from 57% to 22%. - Improvement of the average IIEF5 score: from 14 to 18.75 - Decrease in average plaque size: from 15mm to 6.7mm (55% reduction) - Improvement of PDQ scale in 91% of subjects. No infectious complications were noted. Only one subject reported a minimal hematoma at the injection site during a single session. Conclusions This study requires confirmation in a longer series of cases, but the preliminary results of this safe, reproducible, and very inexpensive protocol are promising and should encourage practitioners to adopt it, especially in low and middle-income countries. Disclosure No

MP62-20 EFFECTS OF ADJUVANT DEXMEDETOMIDINE IN DORSAL PENILE BLOCK FOR PENILE PROSTHESIS IMPLANTATION

You have accessJournal of UrologyCME1 Apr 2023MP62-20 EFFECTS OF ADJUVANT DEXMEDETOMIDINE IN DORSAL PENILE BLOCK FOR PENILE PROSTHESIS IMPLANTATION Kikuye Sugiyama, Amanda Swanton, Tejash Shah, and Ricardo Munarriz Kikuye SugiyamaKikuye Sugiyama More articles by this author , Amanda SwantonAmanda Swanton More articles by this author , Tejash ShahTejash Shah More articles by this author , and Ricardo MunarrizRicardo Munarriz More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003320.20AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Inflatable penile prosthesis (IPP) surgery is the gold standard treatment for medication-refractory erectile dysfunction. While highly satisfactory, post-operative pain and narcotic requirement remains a concern. Use of intraoperative dorsal penile nerve block with long acting local anesthetic can improve postoperative analgesia. Recent studies in non-urologic fields have demonstrated prolonged analgesia with minimal adverse effects with local nerve blocks containing long acting local anesthetic with either dexamethasone or dexmedetomidine. This study aims to evaluate the analgesic efficacy of these adjuvants in bupivacaine penile nerve block as compared to a bupivacaine-only block during primary IPP surgery. METHODS: This is a retrospective single institution IRB-approved comparative study of patients undergoing primary IPP placement receiving intraoperative dorsal penile nerve block with either 0.25% bupivacaine (2019) versus combination block with 0.25% bupivacaine+70 µg dexmedetomidine+4 mg dexamethasone (2020 - 2021). The primary outcome was pain during the first 24 hours post-operatively (0, 2, 6, 12, 18, and 24 hrs) while secondary outcomes were intra- and postoperative narcotic use, intraoperative hypotension defined here as MAP<60 for more than 5 minutes or requiring intervention, and intraoperative bradycardia defined here as HR<50 for more than a minute. RESULTS: Of 98 the patients included, 32 received bupivacaine only and 66 received the combination block. Mean PACU pain in the first 24 hours at all times (0, 2, 6, 12, 18, 24 hrs) were significantly lower in the combination block group (1.1 vs 3.8, 1.6 vs 3.9, 3.1 vs 4.9, 2.4 vs 4.3, 2.9 vs 5.3, 2.3 vs 4.4; p<0.05). Mean total postoperative narcotics was lower for the combination block (46 vs 65, p<0.05). There was no significant difference in intraoperative narcotics between groups (111 vs 132; p=0.133). Of patients who received the combination block, 4 had intraoperative hypotension of MAP<60 for more than 5 minutes and 114 had bradycardia below 50 but did not require intervention. CONCLUSIONS: Intraoperative dorsal penile nerve block consisting of long acting local anesthetic mixed with dexmedetomidine and dexamethasone can safely enhance immediate post-operative analgesia and decrease opioid consumption in the first 24 hours after surgery. A prospective randomized study is underway to further evaluate outcomes. This type of combination penile nerve block may also be a useful tool for other penile and scrotal surgeries. Source of Funding: Unfunded © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e870 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Kikuye Sugiyama More articles by this author Amanda Swanton More articles by this author Tejash Shah More articles by this author Ricardo Munarriz More articles by this author Expand All Advertisement PDF downloadLoading ...

MP18-09 LIPOSOMAL BUPIVACAINE PLUS BUPIVACAINE VS. BUPIVACAINE ALONE IN PEDIATRIC PATIENTS UNDERGOING UROLOGIC SURGERY: PRELIMINARY REPORT FROM THE BABY ORIOLES TRIAL

You have accessJournal of UrologyCME1 Apr 2023MP18-09 LIPOSOMAL BUPIVACAINE PLUS BUPIVACAINE VS. BUPIVACAINE ALONE IN PEDIATRIC PATIENTS UNDERGOING UROLOGIC SURGERY: PRELIMINARY REPORT FROM THE BABY ORIOLES TRIAL Andrew Gabrielson, Tamir Sholklapper, Chad Crigger, Logan Galansky, Kelly Harris, Hiten PATEL, Nora Haney, Ming-Hsien Wang, Charlotte Wu, John Gearhart, and Heather Di Carlo Andrew GabrielsonAndrew Gabrielson More articles by this author , Tamir SholklapperTamir Sholklapper More articles by this author , Chad CriggerChad Crigger More articles by this author , Logan GalanskyLogan Galansky More articles by this author , Kelly HarrisKelly Harris More articles by this author , Hiten PATELHiten PATEL More articles by this author , Nora HaneyNora Haney More articles by this author , Ming-Hsien WangMing-Hsien Wang More articles by this author , Charlotte WuCharlotte Wu More articles by this author , John GearhartJohn Gearhart More articles by this author , and Heather Di CarloHeather Di Carlo More articles by this author View All Author Informationhttps://doi.org/10.1097/JU.0000000000003238.09AboutPDF ToolsAdd to favoritesDownload CitationsTrack CitationsPermissionsReprints ShareFacebookLinked InTwitterEmail Abstract INTRODUCTION AND OBJECTIVE: Long-acting liposomal bupivacaine (Exparel) was approved for children >6 years old however it has not been evaluated in children undergoing urologic surgery. We report preliminary safety and efficacy data of Exparel plus bupivacaine vs. bupivacaine alone for incisional infiltration or penile block in pediatric patients undergoing ambulatory urologic surgery as part of a randomized trial. METHODS: The study is an IRB-approved prospective, single-blinded trial randomizing patients 6-18 years old 1:1 to receive Exparel plus 0.25% bupivacaine (experimental) vs. 0.25% bupivacaine alone (control) during ambulatory urology procedures (NCT04826484). Patients received Tylenol and Ibuprofen prescriptions and a rescue prescription of 3-5 doses 0.1 mg/kg Oxycodone. Efficacy endpoints include percent requiring no opioids within 48hr and 10-14d, parents’ postoperative pain measure (PPPM) scores at 48hr and 10-14d, and oral morphine equivalents (OMEQ) per kg given through 10-14d. RESULTS: A total of 52 patients (29 control, 23 experimental) have been enrolled. Demographic, procedural, efficacy, and safety data are summarized in Table 1. There was no difference in percentage of patients requiring no post-operative opioids through 48hr (57% vs 55%, p=0.92). There was no difference in mean FLACC score in PACU (0.9 vs 1.2, p=0.64), PPPM score at 48hr (2.5 vs. 3.5, p=0.09) or PPPM score at 10-14d (0.55 vs. 0.6, p=0.67). The experimental arm had significantly reduced OMEQ/kg at 10-14d (0.06 vs. 0.2, p=0.02). However, OMEQ/kg utilization was low and limited to the 48hr post-op period in both arms. There were no intraoperative complications and similar use of perioperative Ketorlac between arms. Roughly 10% of patients in both arms had an unplanned phone call or message to the office (all related to swelling). No patients had unplanned presentation to the emergency department. CONCLUSIONS: This prospective, single-blinded randomized trial is the first to evaluate Exparel in pediatric patients undergoing urologic surgery. We demonstrate that albeit safe, the addition of Exparel to 0.25% bupivacaine did not improve validated pain scores or opioid-free rate at 48 hours. Formal assessment of efficacy and safety pending trial accrual. Source of Funding: Internally funded © 2023 by American Urological Association Education and Research, Inc.FiguresReferencesRelatedDetails Volume 209Issue Supplement 4April 2023Page: e226 Advertisement Copyright & Permissions© 2023 by American Urological Association Education and Research, Inc.MetricsAuthor Information Andrew Gabrielson More articles by this author Tamir Sholklapper More articles by this author Chad Crigger More articles by this author Logan Galansky More articles by this author Kelly Harris More articles by this author Hiten PATEL More articles by this author Nora Haney More articles by this author Ming-Hsien Wang More articles by this author Charlotte Wu More articles by this author John Gearhart More articles by this author Heather Di Carlo More articles by this author Expand All Advertisement PDF downloadLoading ...

Comparison of Post-Operative Analgesic Efficacy of Caudal Epidural Block versus Penile Block in Children Undergoing Hypospadias

Objective: To compare the post-operative analgesic efficacy of penile block vs caudal block following hypospadias repair.&#x0D; Study Design: Quasi-experimental study.&#x0D; Place and Duration of Study: Pediatric and Plastic Surgery Departments, Combined Military Hospital, Multan Pakistan, from Jul 2019 to Jul 2021.&#x0D; Methodology: The total of 34 patients undergoing hypospadias operation was booked for this study after approval of the ethical committee. All patients were operated on under General anaesthesia. The booked patients were randomly divided into Groups 1 and 2. For post-operative analgesia, the first group got penile block while the latter was given caudal epidural block.&#x0D; Results: The mean age of the patients was 3.99±2.68 years. These patients were split into two groups. Group-1 (n=17)underwent a Penile block, and Group-2 (n=17) underwent a Caudal block. There were no serious complications after a penile block or caudal block. A substantial decline in pain scores was noted, more in the penile block group.&#x0D; Conclusion: For patients being treated for Hypospadias, the penile block is a more effective and simple method of pain control post-operatively. This can be performed by the surgeon.

Caudal anesthesia is not associated with post-operative complications following distal hypospadias repair

The use of caudal anesthesia at the time of hypospadias repair remains controversial as some prior studies have reported increased postoperative complication rates associated with caudal nerve block. However, these results have been called into question due to confounding factors and heterogeneous study groups. Given the importance of identifying true risk factors associated with increased hypospadias complication rate, we examined our experience with caudal anesthesia limiting our analysis to distal repairs. We hypothesized that caudal anesthesia would not be associated with increased postoperative complications. We retrospectively reviewed our institutional hypospadias database from June 2007 to January 2021. All boys who underwent single-stage distal hypospadias repair with either caudal or penile block with minimum 1 month follow up were included. Records were reviewed to determine the type of local anesthesia, type of hypospadias repair, all complications, and time to complication. Association between any complication and local anesthesia type was evaluated by univariate and multivariate logistic regression analysis controlling for age at surgery and type of repair. A sub-analysis was performed for complications occurring ≤30 days. Overall, 1008 boys, 832 (82.5%) who received caudal and 176 (17.5%) penile block, were included. Median age at surgery was 8.1 months and median follow up was 13 months. Overall complication rate was 16.4% with 13.8% of patients requiring repeat operation. Median time to complication was 10.59 months and was significantly shorter in the caudal group (8.45 vs. 25.2 months). Caudal anesthesia was associated with higher likelihood of complication on univariate analysis; however, this was not true on multivariate analysis when controlling for age and type of repair. Caudal anesthesia was not associated with increased likelihood of complication within 30 days. Since the association between caudal anesthesia and hypospadias complications was first suggested, several studies have tried to answer this question with variable results. Our findings add to the evidence that there is no association between caudal anesthesia and increased hypospadias complications in either the short or long term. The major strengths of our study are a large, homogenous study population, robust follow up and inclusion of data from 14 surgeons over 14 years. Limitations include the study's retrospective nature as well as lack of standardized follow up protocol throughout the study period. After controlling for possible confounders, caudal nerve block was not associated with increased risk of postoperative complications following distal hypospadias repair.

Comparing Postoperative Analgesia of Caudal and Penile Blockade using Bupivacaine in Children Undergoing Hypospadias Repair

Background &amp; Objectives: Caudal epidural and dorsal nerve penile blockade are commonly used for analgesia during and after hypospadias repair in children. Comparative studies to recommend the most effective block are in dearth. This study aims to compare penile block versus caudal block with bupivacaine for hypospadias repair in children in terms of post-operative effectiveness, pain management, and complications. Methodology: The study was conducted on 60 male children, aged 1-9 years, undergoing hypospadias surgery under general anesthesia. The subjects were randomly divided into two groups: (A: caudal block, n=30, and B: penile block, n=30). A postoperative pain assessment was conducted using FLACC scale until 24 hours post-surgery. Results: The patients from the A and B groups were comparable in age, weight, and ASA classification. All patients in the 2 groups did not feel pain post-operatively throughout the first 6 hours. One patient (3.4%) from each of the A and B groups started to feel pain 6 hours, and 9 hours, respectively after surgery. Eight patients (26.7%) in group A and 6 patients (20%) in group B felt pain throughout 6 to 24 hours after surgery. Four patients from group A and 1 patient from group B developed nausea and vomiting during the first 24 hours post-surgery. Conclusion: The penile blockade proved to be more effective in lowering postoperative pain scores, with fewer side effects, thereby decreasing the need for rescue analgesia.

Hyaluronic acid injection for the management of peyronie's disease

To report our findings in terms of safety and efficacy of intralesional injections of hyaluronic acid (IIHA) in the treatment of Peyronie's disease (PD). Data were extrapolated from a single centre prospectively maintained database. 18 patients with PD received IIHA using the same procedure as for collagenase clostridium histolyticum. Penile curvature assessed through Intracavernosal injection of prostaglandin E1, Peyronie's Disease Questionnaire (PDQ) and the International Index of Erectile Function (IIEF) were carried out at baseline and at week 7. The Global Assessment of Peyronie's Disease (GAPD) questionnaire was completed at week 7. No patients received previous local treatment for PD and all had at least 1 year stable disease. IIHA were performed every other week under penile block of 15 mL plain mepivacaine 1% for total number of 3 injections in six weeks; investigator modelling has been fulfilled at the end of each injection. Patients were educated to home modeling, stretching and using daily vacuum device between injections. The median penile curvature at baseline was 55 (IQR= 43.75 - 65). Of the treated patients 16 (88%) showed a decrease in the angle of curvature by a mean of 13.33 ± 8.57 degrees. At 7 weeks the median measured curvature was 40 (IQR = 30 – 50) (p<0.001). A statistically significant improvement in IIEF- Intercourse Satisfaction (from 30,1 ± 7.1 to 34.7 ± 8.1; p<0.001). Hyaluronic acid injections were well tolerated by all patients and no complications were observed. Our preliminary study showed that IIHA may reduce penile curvature in patients affected by Peyronie's Disease in combination with the use of vacuum device, penile modelling and stretching. Considering the safety, the low cost and efficacy, we believe that IIHA may be a promising treatment option. The authors reported no conflict of interest.

Effects of Caudal and Penile Blocks on the Complication Rates of Hypospadias Repair

Background:The major influencing factors for complications during hypospadias repair are the original location of the meatus, previous urethral surgery, surgical technique, and surgeon’s experience. While the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.hile the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.Aims:To determine the effect of caudal block and penile block on complication rates of hypospadias repair in patients with subcoronal hypospadias.Study Design:Retrospective cross-sectional study.Methods:Data of children who underwent hypospadias repair between 2011 and 2019 in our clinic (n = 770) were reviewed retrospectively. Only patients with subcoronal hypospadias and who underwent tubularized incised plate urethroplasty, performed by the same two experienced surgeons (n = 279), were included in the study. The exclusion criteria were incomplete data and follow-up time shorter than 12 months. Data of 279 patients were analyzed. Patients were divided into two groups according to the analgesia type: caudal block (n = 95) and penile block (n = 184), and complication rates were compared between these groups.Results:The median age was 36 months in the caudal block group and 30 months in the penile block group (P = 0.390). The median follow-up times were 54 and 42.7 months in the caudal and penile block groups, respectively. Total complication rates did not differ significantly between the groups and were determined as 10.5% and 12.5% in the caudal and penile groups, respectively. Urethrocutaneous fistula rates were observed as 2.1% and 4.3% (p=0.50). None of the patients had penile chordee and no penile plication was performed in the whole group.Conclusion:This study shows that there is no increase in post-repair complications in patients with subcoronal hypospadias who underwent caudal block.