Dorsal Penile Nerve Block via Perineal Approach, an Alternative to a Caudal Block for Pediatric Circumcision: A Randomized Controlled Trial

Xiaocou Wang, Chaoxuan Dong, Deepti Beekoo, Xiaowei Qian, Jun Li, Wang-Ning Shang-Guan, Xuebin Jiang, Xiaocou Wang, Chaoxuan Dong, Deepti Beekoo, Xiaowei Qian, Jun Li, Wang-Ning Shang-Guan, Xuebin Jiang

Abstract

Background: General anesthesia combining with a caudal block (CB) has been commonly performed in pediatric patients undergoing circumcision surgeries. However, some severe complications have been suspected of a caudal block in the combined use. To avoid these issues of a caudal block, this study introduces a novel dorsal penile nerve block (DPNB) via perineum guided by ultrasound as an alternative to a caudal block in pediatric circumcision surgeries.

Methods: A total of 104 pediatric patients scheduled for circumcision surgeries were involved and randomly divided into 2 groups: the CB group (n=52) and the DPNB group (n=52). A laryngeal mask was inserted followed by induction and maintenance anesthesia of inhaled sevoflurane. In the DPNB group, a dorsal penile nerve block (DPNB) guided by a real-time ultrasonography was performed by a single injection via perineum of 0.25% ropivacaine plus 0.8% lidocaine with total injection volume of 3-5ml. In the CB group, a dose of 0.5 ml/kg was given via the caudal canal following the same general anesthesia with that of Group DPNB. The time to the first analgesic demand after surgery is the key data collected for comparing between the two study groups. Heart rates and respiratory rates changes before and during the surgical procedure, pain score when leaving the PACU, and the time taken for the first micturition after a surgery were also recorded to analyze the differences in analgesic effects between the CB and DPNB groups.

Results: No significant difference in heart rates and respiratory rates was found between the two groups before and during the surgery. Pain scores were similar before pediatric patients leave the PACU. However, the time taken for the first micturition after a surgery in Group DPNB is shorter than Group CB. The patients in Group DPNB asked for analgesics later than those in Group CB. Additionally, no significant differences in adverse effects were noted between two groups except the numbness of the lower limbs occurring less in Group DPNB.

Conclusions: The ultrasound-guided dorsal penile nerve block via perineal approach can basically act as a safe and effective alternative to the caudal block in pediatric patients undergoing circumcision surgeries. Clinical Trials identifier is ChiCTR-IPR-15006670. Protocol is available at http://www.chictr.org.cn/showproj.aspx?proj=11319.

Figures

Figure 1
Figure 1
The position of the ultrasonic probe in the dorsal penile nerve block via perineal approach. For all patients of Group DPNB, a lithotomy position was adopted to fully expose the perineum. A linear array probe (5 to 10 MHz or 10-20 MHz) was used for an ultrasound guiding procedure. The probe was placed beneath the skin of the scrotum in a coronal parallel plane and scanned by a Sonosite M-Turbo (SonoSite, Bothell, WA, USA).
Figure 2
Figure 2
The ultrasound-guided dorsal penile nerve block via perineal approach. (a) an ultrasound image of a penile neurovascular sheath before a complete nerve block injection; (b) an ultrasound image of a penile neurovascular sheath after a complete DPNB injection. On the ultrasound image, injected local anesthetics were shown as a black hypoechoic area, firstly filled in one side of the neurovascular sheath and then spread to the opposite side.
Figure 3
Figure 3
A CONSORT flow diagram of this study.
Figure 4
Figure 4
Changes in heart rates and respiratory rates before and during the surgical procedures between the two groups: Group DPNB, the dorsal penile nerve block, and Group CB, the caudal block. Image (a) heart rates; Image (b) respiratory rates. T1, the time before any anesthesia procedure baseline (the data collected from the medical records); T2, the time-point after on inserting a laryngeal mask; T3, the time on removing when the prepuce is removed; T4, when the time on stitching the last part of prepuce; T5, time-point the time after on pulling out the laryngeal mask. A P value less than 0.05 is considered as a statistical significance. No significant change in HRs and RRs between the two groups is found.

References

    1. American Academy of Pediatrics Task Force on Circumcision. Male circumcision. Pediatrics. 2012;130(3):e756–e785. doi: 10.1542/peds.2012-1990.
    1. Morris B. J., Bailis S. A., Castellsague X., Wiswell T. E., Halperin D. T. RACP's policy statement on infant male circumcision is ill-conceived. Australian and New Zealand Journal of Public Health. 2006;30(1):16–22. doi: 10.1111/j.1467-842X.2006.tb00079.x.
    1. Ding X., Jin B., Ling F., Cai Y., Zheng H. The progress of treatment on children phimosis. The Chinese Journal of Human Sexuality. 2016;25(8):26–29.
    1. Soh C. R., Ng S. B. A., Lim S. L. Dorsal penile nerve block. Pediatric Anesthesia. 2003;13(4):329–333. doi: 10.1046/j.1460-9592.2003.01033.x.
    1. O'Sullivan M. J., Mislovic B., Alexander E. Dorsal penile nerve block for male pediatric circumcision - Randomized comparison of ultrasound-guided vs anatomical landmark technique. Pediatric Anesthesia. 2011;21(12):1214–1218. doi: 10.1111/j.1460-9592.2011.03722.x.
    1. Naja Z., Al-Tannir M. A., Faysal W., Daoud N., Ziade F., El-Rajab M. A comparison of pudendal block vs dorsal penile nerve block for circumcision in children: a randomised controlled trial. Anaesthesia. 2011;66(9):802–807. doi: 10.1111/j.1365-2044.2011.06753.x.
    1. Choi W. Y., Irwin M. G., Hui T. W. C., Lim H. H., Chan K. L. EMLA® cream versus dorsal penile nerve block for postcircumcision analgesia in children. Anesthesia & Analgesia. 2003;96(2):396–399. doi: 10.1097/00000539-200302000-00018.
    1. Dostbil A., Gursac Celik M., Aksoy M., et al. The effects of different doses of caudal morphine with levobupivacaine on postoperative vomiting and quality of analgesia after circumcision. Anaesthesia and Intensive Care. 2014;42(2):234–238. doi: 10.1177/0310057X1404200211.
    1. Qian X., Jin X., Chen L., Pan Y., Wu B., Li J. A new ultrasound-guided dorsal penile nerve block technique for circumcision in children. Anaesthesia and Intensive Care. 2015;43(5):662–663.
    1. Taylor R., Eyres R., Chalkiadis G. A., Austin S. Efficacy and safety of caudal injection of levobupivacaine, 0.25%, in children under 2 years of age undergoing inguinal hernia repair, circumcision or orchidopexy. Pediatric Anesthesia. 2003;13(2):114–121. doi: 10.1046/j.1460-9592.2003.01036.x.
    1. Suresh S., Long J., Birmingham P. K., De Oliveira G. S. Are caudal blocks for pain control safe in children? An analysis of 18,650 caudal blocks from the Pediatric Regional Anesthesia Network (PRAN) database. Anesthesia & Analgesia. 2015;120(1):151–156. doi: 10.1213/ANE.0000000000000446.
    1. Kundra P., Yuvaraj K., Agrawal K., Krishnappa S., Kumar L. T. Surgical outcome in children undergoing hypospadias repair under caudal epidural vs penile block. Pediatric Anesthesia. 2012;22(7):707–712. doi: 10.1111/j.1460-9592.2011.03702.x.
    1. Taicher B. M., Routh J. C., Eck J. B., Ross S. S., Wiener J. S., Ross A. K. The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair. Pediatric Anesthesia. 2017;27(7):688–694. doi: 10.1111/pan.13119.
    1. Richard L. D., Wayne V., Adam W. M. M. Gray's Anatomy for Students. 1st. Singapore: Elsevier; 2005.
    1. Sandeman D. J., Reiner D., Dilley A. V., Bennett M. H., Kelly K. J. A retrospective audit of three different regional anaesthetic techniques for circumcision in children. Anaesthesia and Intensive Care. 2010;38(3):519–524. doi: 10.1177/0310057X1003800317.
    1. Margetts L., Carr A., McFadyen G., Lambert A. A comparison of caudal bupivacaine and ketamine with penile block for paediatric circumcision. European Journal of Anaesthesiology. 2008;25(12):1009–1013. doi: 10.1017/S0265021508004833.
    1. Faraoni D., Gilbeau A., Lingier P., Barvais L., Engelman E., Hennart D. Does ultrasound guidance improve the efficacy of dorsal penile nerve block in children? Pediatric Anesthesia. 2010;20(10):931–936. doi: 10.1111/j.1460-9592.2010.03405.x.
    1. Gauntlett I. A comparison between local anaesthetic dorsal nerve block and caudal bupivacaine with ketamine for paediatric circumcision. Pediatric Anesthesia. 2003;13(1):38–42. doi: 10.1046/j.1460-9592.2003.00926.x.

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