Nerve stimulator-guided pudendal nerve block vs general anesthesia for postoperative pain management after anterior and posterior vaginal wall repair: a prospective randomized trial

Analgesic benefits of regional anesthesia in the perioperative management of transition-related surgery: a systematic review

INTRODUCTION

Transition-related surgery is an effective treatment for gender dysphoria, but the perioperative analgesic management of transgender patients is nuanced and potentially complicated by higher rates of mood and substance use disorders. Regional anesthetic techniques are known to reduce pain severity and opioid requirements; however, little is known regarding the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery.

METHODS

We performed a systematic review of the literature to evaluate original reports characterizing the analgesic effectiveness of regional anesthetic techniques for patients undergoing chest and/or genital transition-related surgery. Our primary outcomes were pain severity and opioid requirements on the first postoperative day.

RESULTS

Of the 1863 records identified, 10 met criteria for inclusion and narrative synthesis. These included two randomized controlled trials, three cohort studies, and five case reports/series, comprising 293 patients. Four reports described 243 patients undergoing chest surgery, of whom 86% were transgender men undergoing mastectomy with pectoralis nerve blocks or local anesthetic instillation devices. The remaining six reports comprised 50 patients undergoing genital surgery, of whom 56% were transgender women undergoing vaginoplasty with erector spinae plane blocks or epidural anesthesia. Three studies directly compared regional techniques to parenteral analgesia alone. Two of these studies reported lower pain scores and opioid requirements on the first postoperative day with nerve blocks compared with none while the third study reported no difference between groups. Complications related to regional anesthetic techniques were rare among patients undergoing transition-related surgery.

DISCUSSION

Despite the ever-growing demand for transition-related surgery, the relative analgesic effectiveness of regional anesthesia for transgender patients undergoing transition-related surgery is very understudied and insufficient to guide clinical practice. Our systematic review of the literature serves to underscore regional anesthesia for transition-related surgery as a priority area for future research.

Does pudendal nerve block improve perioperative pain following OnabotulinumtoxinA injection for myofascial pelvic pain?

OBJECTIVE

OnabotulinumtoxinA (BTA) injections are useful for treatment of myofascial pelvic pain. Concurrent pudendal nerve block (PNB) has been suggested to decrease postoperative pain, as BTA does not take an immediate effect. The efficacy of PNB for this purpose has not been well elucidated. We aim to determine if PNB improves pain in the postoperative period following pelvic floor BTA injections.

DESIGN

A subgroup analysis was performed from a retrospective cohort study including 202 patients encompassing 416 BTA injections at a single high volume, academic institution. Post Anesthesia Care Unit (PACU) visual analog scale (VAS) pain score and oral morphine equivalents (OME) data between 2018 and 2022 were reviewed.

RESULTS

A total of 64 patients met inclusion criteria, encompassing 96 BTA injection events. Thirty-three BTA injections were done with concurrent PNB (BTA/PNB), while 63 injections were performed without PNB (BTA). Demographics of patients were similar in both groups. Mean VAS upon discharge from PACU was 1.7 for BTA alone and 1.9 for BTA/PNB (p = 0.610). Mean time (minutes) in PACU was 100.7 for BTA alone and 100.5 for BTA/PNB (p = 0.692). Mean OMEs given in PACU were 12.5 for BTA alone and 15.0 for BTA/PNB (p = 0.443).

CONCLUSION

This study may suggest a limited benefit of PNB at improving postoperative pain following pelvic floor BTA injection. Additional research is needed to determine the efficacy of PNB at time of pelvic floor BTA injections.

Protocol of a clinical trial on the effectiveness of pudendal nerve block with and without neurostimulation in reducing posthemorroidectomy pain

INTRODUCTION

Hemorrhoidal pathology is the most frequent proctological problem with a prevalence of 44% of the adult population. The most effective treatment is surgery but it also has the highest postoperative pain rate with moderate to severe pain rates of 30-40% during the first 24-48 hours. Here lies the importance of seeking measures to improve this situation, such as the pudendal nerve block with local anesthetic. However, the variability of the pudendal nerve sometimes makes its blockade ineffective and for this reason nerve location methods are sought to achieve a higher rate of success. The main aim of the study is to compare pain in the immediate postoperative period (24 h) after hemorrhoidectomy in patients with pudendal nerve block guided by anatomical references and guided by neurostimulation.

METHODS

The present project proposes the performance of a single-center, triple-blind, randomized clinical trial of efficacy, carried out under conditions of routine clinical practice. Patients over 18 years old with hemorrhoids refractory to medical treatment, symptomatic grade III-IV and grade II hemorrhoids that do not respond to conservative procedures in a third level hospital in Spain and that are subsidiaries of surgery in major ambulatory surgery will be included. Demographic variables, variables on hemorrhoidal pathology, details of surgery, verbal numeric pain scale in the preoperative period and surgical complications will be collected.

RESULTS

Not avaliable until the end of the study.

CONCLUSIONS

The pudendal nerve block guided by anatomical landmarks has been shown to be useful in postoperative pain control after hemorrhoidectomy although the use of the neurostimulator has not been well studied and we believe it may improve outcom.

Pudendal Block at the Time of Transvaginal Prolapse Repair: A Randomized Controlled Trial

IMPORTANCE

The utility of pudendal nerve blocks (PNBs) at the time of transvaginal surgery is mixed in the literature. No published study has evaluated the efficacy of PNB since the widespread adoption of Enhanced Recovery After Surgery (ERAS) pathways.

OBJECTIVE

This study aimed to determine if PNB, in addition to ERAS measures, at the time of vaginal reconstructive surgery reduces opioid use in the immediate postoperative period.

STUDY DESIGN

In this randomized, blinded, controlled trial, women scheduled for transvaginal multicompartment prolapse repair were randomized to bilateral PNB before incision with 20 mL of 0.5% bupivacaine versus usual care. Primary outcome was opioid use in morphine milligram equivalents (MME) for the first 24 hours. The study was powered to detect a 5.57-MME difference in opioid use in the first 24 hours between groups.

RESULTS

Forty-four patients were randomized from January 2020 to April 2022. The PNB and control groups were well matched in demographic and surgical data. There was no difference in opioid use in first 24 hours between the control and PNB groups (8 [0-20] vs 6.7 [0-15]; P = 0.8). Median pain scores at 24 and 48 hours did not differ between groups (4 ± 2 vs 3 ± 3; P = 0.44) and 90% of participants were satisfied with pain control across both groups. Time to return to normal activities (median, 10 days) was also not different between the groups.

CONCLUSIONS

Because pain satisfaction after transvaginal surgery in the era of ERAS is high, with overall low opioid requirements, PNB provides no additional benefit.

Pudendal Nerve Block Analgesia at the Time of Vaginal Surgery: A Randomized, Double-Blinded, Sham-Controlled Trial

IMPORTANCE

Effective opioid-sparing postoperative analgesia requires a multimodal approach. Regional nerve blocks augment pain control in many surgical fields and may be applied to pelvic floor reconstruction.

OBJECTIVE

This study aimed to evaluate the impact of pudendal nerve block on postoperative pain control and opioid consumption after vaginal surgery.

STUDY DESIGN

In this randomized, double-blind, sham-controlled trial, we enrolled women undergoing pelvic reconstruction, excluding patients with chronic pelvic pain or contraindications to nonnarcotic analgesia. Patients were randomized to transvaginal pudendal nerve block (9 mL 0.25% bupivacaine and 1 mL 40 mg/mL triamcinolone) or sham injection (10 mL normal saline). Primary outcomes were pain scores and opioid requirements. Sixty patients were required to show a 20-mm difference on a 100-mm visual analog scale (VAS).

RESULTS

We randomized 71 patients: 36 pudendal block and 35 sham. Groups were well matched in baseline characteristics and surgery type. Prolapse repairs were most common (n = 63 [87.5%]), and there was no difference in anesthetic dose or operative time. Pain scores were equivalent in the postanesthesia care unit (mean VAS, 53.1 [block] vs 56.4 [sham]; P = 0.517) and on postoperative day 4 (mean VAS, 26.7 [block] vs 35.5 [sham]; P = 0.131). On postoperative day 1, the intervention group reported less pain, but this did not meet our 20 mm goal for clinical significance (mean VAS, 29.2 vs 42.5; P = 0.047). A pudendal block was associated with lower opioid consumption at all time points, but this was not statistically significant.

CONCLUSIONS

Surgeon-administered pudendal nerve block at the time of vaginal surgery may not significantly improve postoperative pain control or decrease opioid use.

Pre-emptive digitally guided pudendal block after posterior vaginal repair

Introduction and hypothesis

The aim of this study was to establish if digitally guided pre-emptive pudendal block (PDB) reduces postoperative pain and facilitates recovery after posterior vaginal repair under local anesthesia and sedation.

Methods

We carried out a prospective, randomized, double-blind trial in an outpatient surgery facility. Forty-one women between 18 and 70 years of age, scheduled for primary posterior vaginal reconstructive outpatient surgery, completed the study. The surgery was performed using sedation and local anesthesia with bupivacaine/adrenaline. At the end of surgery, 20 ml of either ropivacaine 7.5 mg/ml or sodium chloride (placebo) was administered as a digitally guided PDB. The primary aim was to establish if PDB with ropivacaine compared with placebo reduced the maximal pain as reported by visual analog scale (VAS) during the first 24 h after surgery. Secondary aims were to compare the duration and experience of the hospital stay, nausea, need for additional opioids, and adverse events.

Results

PDB with ropivacaine after local infiltration with bupivacaine/adrenaline after outpatient posterior repair did not significantly reduce maximal postoperative pain, need for hospital admittance, nausea, or opioid use. Mild transient sensory loss occurred after ropivacaine in two women. Two women the placebo group were unable to void owing to severe postoperative pain, which was resolved by a rescue PDB.

Conclusions

When bupivacaine/adrenaline is used for anesthesia in posterior vaginal repair, PDB with ropivacaine gives no benefit regarding postoperative pain, recovery or length of hospital stay. Rescue PDB can be useful for postoperative pain relief.

A systematic review of reported outcomes and outcome measures in randomized trials evaluating surgical interventions for posterior vaginal prolapse to aid development of a core outcome set

BACKGROUND

Recent systematic reviews have demonstrated wide variations on outcome measure selection and outcome reporting in trials on surgical treatments for anterior, apical and mesh prolapse surgery. A systematic review of reported outcomes and outcome measures in posterior compartment vaginal prolapse interventions is highly warranted in the process of developing core outcome sets.

OBJECTIVE

To evaluate outcome and outcome measures reporting in posterior prolapse surgical trials.

SEARCH STRATEGY

We searched MEDLINE, EMBASE and the Cochrane Central Register of Controlled Trials (CENTRAL).

SELECTION CRITERIA

Randomized trials evaluating the efficacy and safety of different surgical interventions for posterior compartment vaginal prolapse.

DATA COLLECTION AND ANALYSIS

Two researchers independently assessed studies for inclusion, evaluated methodological quality, and extracted relevant data. Methodological quality, outcome reporting quality and publication characteristics were evaluated.

MAIN RESULTS

Twenty-seven interventional and four follow-up trials were included. Seventeen studies enrolled patients with posterior compartment surgery as the sole procedure and 14 with multicompartment procedures. Eighty-three reported outcomes and 45 outcome measures were identified. The most frequently reported outcomes were blood loss (20 studies, 74%), pain (18 studies, 66%) and infection (16 studies, 59%).

CONCLUSIONS

Wide variations in reported outcomes and outcome measures were found. Until a core outcome set is established, we propose an interim core outcome set that could include the three most commonly reported outcomes of the following domains: hospitalization; intraoperative, postoperative urinary, gastrointestinal, vaginal and sexual outcomes; clinical effectiveness.

PROSPERO

CRD42017062456.

High Patient Satisfaction With Local Anesthesia and Light Sedation in a Novel Fast-Track Setup for Sacrospinous Fixation

OBJECTIVES

Simple prolapse operations can be performed using local anesthesia. However, this has not been the case for advanced pelvic organ prolapse operations. The aim of this study was to investigate the patient-reported feasibility and acceptability of local anesthesia and light sedation for sacrospinous fixation (SSF).

METHODS

This is a prospective observational study on 105 women who underwent SSF in a public outpatient setting from April 2016 to October 2017. They received infiltration anesthesia with mepivacaine or lidocaine together with a pudendal nerve block with Marcaine. Local anesthesia was supplemented by intravenous light sedation and pain reliever. A Local Anesthetic Intraoperative Experience Questionnaire was used to evaluate patient experience.

RESULTS

One patient was converted to general anesthesia. Eighty-eight women answered the questionnaires. Ninety-nine percent defined themselves as satisfied or very satisfied with the anesthesia. Little or no pain during the operation was reported by 92% and 92% would choose the same type of anesthesia again. No adverse effect of the anesthetic procedure was observed. The median (range) admission time was 12 (4.5-48) hours, and 81% of the patients could be discharged on the day of surgery. At follow-up after 8 weeks and 6 months, no patients reported adverse events to the anesthesia.

CONCLUSIONS

The SSF can be performed using local anesthesia and light sedation with high degree of patient satisfaction. These preliminary data indicate that the concept of ambulatory surgery might be implemented more widely if the use of local anesthesia is also applied to more advanced surgical procedures.

Regional anesthesia to ameliorate postoperative analgesia outcomes in pediatric surgical patients: an updated systematic review of randomized controlled trials

Regional anesthesia is becoming increasingly popular among anesthesiologists in the management of postoperative analgesia following pediatric surgery. The main objective of this review was to systematically evaluate the last 5 years of randomized controlled trials on the role of regional anesthesia techniques in alleviating postoperative pain associated with various pediatric surgical procedures. Forty studies on 2,408 pediatric patients were evaluated. The majority of the articles published from 2013 to 2017 reported that the use of regional anesthesia minimized postoperative pain and reduced opioid consumption. Only a few surgical procedures (cholecystectomy, inguinal hernia repair, and non-laparoscopic major abdominal surgery) reported no significant difference in the postoperative pain relief compared with the standard anesthetic management. The growing number of randomized controlled trials in the pediatric literature is very promising; however, additional confirmation is needed to reinforce the use of specific regional anesthesia techniques to provide optimal postoperative pain relief for a few surgical procedures (reconstructive ear surgery, chest wall deformity, hypospadias, umbilical hernia, cleft palate repair) in pediatric patients. More randomized controlled trials are needed to establish regional anesthesia as an essential component of postoperative analgesia management in children.

A systematic review of outcome and outcome-measure reporting in randomised trials evaluating surgical interventions for anterior-compartment vaginal prolapse: a call to action to develop a core outcome set

Introduction

We assessed outcome and outcome-measure reporting in randomised controlled trials evaluating surgical interventions for anterior-compartment vaginal prolapse and explored the relationships between outcome reporting quality with journal impact factor, year of publication, and methodological quality.

Methods

We searched the bibliographical databases from inception to October 2017. Two researchers independently selected studies and assessed study characteristics, methodological quality (Jadad criteria; range 1–5), and outcome reporting quality Management of Otitis Media with Effusion in Cleft Palate (MOMENT) criteria; range 1–6], and extracted relevant data. We used a multivariate linear regression to assess associations between outcome reporting quality and other variables.

Results

Eighty publications reporting data from 10,924 participants were included. Seventeen different surgical interventions were evaluated. One hundred different outcomes and 112 outcome measures were reported. Outcomes were inconsistently reported across trials; for example, 43 trials reported anatomical treatment success rates (12 outcome measures), 25 trials reported quality of life (15 outcome measures) and eight trials reported postoperative pain (seven outcome measures). Multivariate linear regression demonstrated a relationship between outcome reporting quality with methodological quality (β = 0.412; P = 0.018). No relationship was demonstrated between outcome reporting quality with impact factor (β = 0.078; P = 0.306), year of publication (β = 0.149; P = 0.295), study size (β = 0.008; P = 0.961) and commercial funding (β = −0.013; P = 0.918).

Conclusions

Anterior-compartment vaginal prolapse trials report many different outcomes and outcome measures and often neglect to report important safety outcomes. Developing, disseminating and implementing a core outcome set will help address these issues.