Perioperative Analgesic Effects of Preemptive Ultrasound-Guided Subcostal Transversus Abdominis Plane Block for Percutaneous Nephrolithotomy: A Prospective, Randomized Trial

Analgesic Strategies for Urologic Videolaparoscopic or Robotic Surgery in the Context of an Enhanced Recovery after Surgery Protocol: A Prospective Study Comparing Erector Spinae Plane Block versus Transversus Abdominis Plane Block

Regional anesthesia in postoperative pain management has developed in recent years, especially with the advent of fascial plane blocks. This study aims to compare the ultrasound-guided bilateral erector spinae plane block (ESPB) versus the ultrasound-guided bilateral transversus abdominis plane block (TAPB) on postoperative analgesia after laparoscopic or robotic urologic surgery. This was a prospective observational study; 97 patients (ESPB-group) received bilateral ultrasound-guided ESPB with 20 mL of ropivacaine 0.375% plus 0.5 mcg/kg of dexmedetomidine in each side at the level of T7-T9 and 93 patients (TAPB-group) received bilateral ultrasound-guided TAPB with 20 mL ropivacaine 0.375% or 0.25%. The primary outcome was the postoperative numeric rating scale (NRS) pain score, which was significantly lower in the ESPB group on postoperative days 0, 1, 2, and 3 (p < 0.001) and, consequently, the number of patients requiring postoperative supplemental analgesic rescue therapies was significantly lower (p < 0.001). Concerning the secondary outcomes, consumption of ropivacaine was significantly lower in the group (p < 0.001) and the total amount of analgesic rescue doses was significantly lower in the ESPB-group than the TAPB-group in postoperative days from 2 to 4 (1 vs. 3, p > 0.001). Incidence of postoperative nausea and vomiting was higher in the TAPB group and no block-related complications were observed. Our data indicate that ESPB provides postoperative pain control at least as good as TAPB plus morphine, with less local anesthetic needed.

Performing percutaneous nephrolithotomy under modified local anesthesia

Objective

This pilot study aimed to assess the practicability and effectiveness of percutaneous nephrolithotomy (PCNL) with vacuum-assisted nephrostomy sheaths for patients under modified local anesthesia (m-LA).

Methods

PCNL with a vacuum-assisted nephrostomy sheath under m-LA was performed in 83 patients between November 2020 and May 2021. An 18F or 20F ClearPetra Nephrostomy Sheath connected vacuum aspiration was used in surgery to keep low pressure in the renal pelvis. For LA, lidocaine and ropivacaine hydrochloride were 1:1 mixed and instilled under ultrasound guidance through the percutaneous nephrolithotomy channel directed toward the design calix. Demographic characteristics, stone characteristics, visual analogue scale (VAS) score, vital signs, operation time, complications, and stone clear rate were recorded and analyzed.

Results

All operations were completed. The mean VAS score was 3.9 ± 1.0. The mean operation time was 55.1 ± 23.6 min. The changes for systolic blood pressure, diastolic blood pressure, and heart rate were 3 ± 21 mmHg, 1 ± 14 mmHg, and −6 ± 14 beats/min, respectively. The change for hemoglobin was −10.7 ± 10.9 g/L. The change for C-reactive protein was 5.39 ± 43.1 mg/L. The total stone-free rate was 69.9% (93.8% for simple stones and 54.9% for complex stones).

Conclusion

Performing PCNL with vacuum-assisted nephrostomy sheaths under modified local anesthesia under ultrasound guidance was found to be strongly practical and effective.

The Effect of Transmuscular Quadratus Lumborum Block on Postoperative Opioid Consumption in Patients Undergoing Percutaneous Nephrolithotomy: A Randomized Controlled Study

Background

This study aimed to investigate the effect of ultrasound-guided transmuscular quadratus lumborum block (QLB) on postoperative opioid consumption in patients undergoing percutaneous nephrolithotomy (PCNL).

Methodology

A total of 40 patients aged between 18 and 60 who were classified as American Society of Anesthesiologists status I-II and scheduled for unilateral PCNL were randomly divided into two groups. Patients in Group QLB (n = 20) received a single-shot QLB with 20 mL of 0.25% bupivacaine in the preoperative period. No intervention was performed in the control group (Group C, n = 20). Dermatomes affected by the block procedure were evaluated in the preoperative period in the group of patients who were administered the block procedure. General anesthesia was administered to all patients in both groups. In the postoperative period, opioid consumption, pain scores, side effects related to opioid consumption, and additional analgesic requirements were recorded.

Results

Opioid consumption was significantly lower in Group QLB compared to Group C at all times (p < 0.05). Postoperative visual analog scale (VAS) scores during the movement were significantly lower in Group QLB compared to Group C at all times (p < 0.05). VAS scores at rest were reported to be significantly lower in Group QLB compared to Group C, except for the eighth and twelfth hours (p < 0.05). The requirement for additional analgesic agents was significantly lower in Group QLB compared to Group C (p < 0.05).

Conclusions

QLB reduced postoperative opioid consumption and VAS scores by providing more effective analgesia compared to the control group in patients who underwent PCNL.

Efficacy of ultrasound-guided Transversus Abdominis Plane (TAP) block in inguinal hernia surgery and the immunomodulatory effects of proinflammatory cytokines: prospective, randomized, placebo-controlled study

Background

Tumor Necrosis Factor-α (TNF-α) and Interleukin-1β (IL-1β) are among the cytokines released secondary to the surgical stress response. The objective of this study was to investigate the effect of a Transversus Abdominis Plane (TAP) block on postoperative pain and its immunomodulatory activity through proinflammatory cytokines.

Methods

TAP (study group; n = 40) or p-TAP (placebo group; n = 40). Patients in the TAP group underwent an Ultrasound (US) guided unilateral TAP block using 20-cc 0.5% bupivacaine solution. Patients in the p-TAP group underwent a sham block using 20-cc isotonic solution. The TNF-α and IL-1β levels were measured three times at preoperative hour-0 and postoperative hours 4 and 24. Visual Analog Scale (VAS) scores were recorded at 0-hours, 30-minutes, 4-hours, and 24-hours. Analgesic use within the first 24-hours following surgery was monitored.

Results

The postoperative VAS score was decreased in the TAP group at all time points (0, 4, and 24 hours), and the differences between groups were statistically significant (p <  0.001 for all comparisons). In the TAP group, the TNF-α and IL-1β levels at 4 and 24 hours post operation were significantly lower than the preoperative levels (p <  0.001 for all comparisons).

Conclusion

The TAP block for pre-emptive analgesia enabled effective hemodynamic control during the intraoperative period, provided effective pain control in the postoperative period, and decreased inflammation and surgical stress due to the decreased levels of the proinflammatory cytokines TNF-α and IL-1β in the first postoperative 24 hours, indicating immunomodulatory effect.

Opioid-sparing analgesic effects of peripheral nerve blocks in percutaneous nephrolithotomy: a systematic review

INTRODUCTION

Multimodal analgesia regimens incorporating peripheral nerve blocks (PNB) have demonstrated reduced postoperative pain, opioid use, and recovery time in various disease states. However, this remains a subject of limited investigation in the percutaneous nephrolithotomy (PCNL) domain. In the face of an ongoing opioid epidemic and collective push to enhance prescribing stewardship, we sought to examine the potential opioid-sparing effect of PNB in PCNL.

METHODS

A systematic review of Embase and PubMed was performed to identify all randomized controlled trials evaluating the use of a PNB with general anesthesia (GA) versus GA alone for pain control following PCNL. Studies evaluating neuraxial (epidural and spinal) anesthesia and those without GA as the control arm were excluded.

RESULTS

Seventeen trials evaluating 1012 procedures were included. Five different blocks were identified and evaluated: paravertebral (n=8), intercostal nerve (n=3), quadratus lumborum (n=2), transversus abdominis plane (n=1), and erector spinae (n=3). 9/16 (56%) studies observed lower pain scores with PNB use throughout the 24-hour postop period. By comparison, improved pain scores with PNB were limited to the early (<6 hours) recovery period in 5 studies and 2 found no difference. Total analgesia and opioid requirements were significantly higher in the GA control arm in nearly all studies (12/14, 86%). Operative times were similar and there were no differences in rates of intercostal access or nephrostomy tube insertion between study arms in any trial.

CONCLUSION

While greater analgesic use with GA alone likely minimizes or obscures differences in patient-reported pain scores, PNB may offer a significant opioid-sparing analgesic effect during postoperative recovery after PCNL.

Transversus abdominis plane block in urological procedures: A systematic review and meta-analysis

BACKGROUND

Transversus abdominis plane (TAP) blocks have been shown to successfully reduce pain and opioid consumption after general and gynaecological surgery.

OBJECTIVE

To evaluate whether TAP blocks alleviate pain and opioid consumption after urological procedures.

DESIGN

A systematic review and meta-analysis.

DATA SOURCES

MEDLINE, Embase and CENTRAL.

ELIGIBILITY CRITERIA

Without language restriction, randomised controlled trials (RCTs) that compared the effects of TAP blocks with placebo or no treatment in urological surgery.

MAIN OUTCOME MEASURES

Primary outcomes were pain intensities at rest and movement at 6, 12 and 24 h after surgery. Secondary outcomes were postoperative opioid consumption in the first 24 h after surgery and postoperative nausea and vomiting. We performed meta-analyses using random effects models. Effect sizes were expressed as mean differences for continuous variables. We used the Cochrane risk of bias tool (RoB 2.0) to assess risk of bias.

RESULTS

We analysed 20 RCTs comprising a total of 1239 patients. The risk of bias of the studies was relatively high. TAP blocks significantly reduced postoperative pain at all time points compared with placebo or no treatment. Mean differences on an 11-point pain intensity scale were between 0.55 (95% CI: -0.90, to -0.21; P = 0.002; I2 = 94%) to 1.13 (95% CI: -1.62 to -0.65; P < 0.001; I2 = 95%) less at rest and 0.74 (95% CI: -1.25 to -0.23; P = 0.005; I2 = 79%) to 1.32 (95% CI: -1.83 to -0.81; P < 0.001; I2 = 68%) less on movements. TAP blocks also reduced opioid consumption in the first 24 h after surgery significantly by 12.25 mg (95% CI: -17.99 to -6.52 mg; P < 0.001; I2 = 99%) morphine equivalents. Possibly, this had no influence on postoperative nausea and vomiting (risk ratio: 0.98; 95% CI: 0.66 to 1.45; P = 0.91; I2 = 30%).

CONCLUSION

TAP blocks seem to offer improved analgesia when used after urological surgery. However, due to the large heterogeneity between and the considerable risk of bias within the included studies results should be viewed with caution.

SYSTEMIC REVIEW REGISTRATION

PROSPERO CRD42018112737.

Erector Spinae Plane Block for Perioperative Analgesia after Percutaneous Nephrolithotomy

Erector spinae plane block was recently introduced as an alternative to postoperative analgesia in surgical procedures including thoracoscopies and mastectomies. There are no clinical trials regarding erector spinae plane block in percutaneous nephrolithotomy. The aim of our study was to test the efficacy and safety of erector spinae plane block after percutaneous nephrolithotomy. We analyzed 68 patients, 34 of whom received erector spinae plane block. The average visual analogue scale score 24 h postoperatively was the primary endpoint. The secondary endpoints were nalbuphine consumption and the need for rescue analgesia. Safety measures included the mean arterial pressure, Ramsey scale score, and rate of nausea and vomiting. The visual analogue scale, blood pressure, and Ramsey scale were assessed simultaneously at 1, 2, 4, 6, 12, and 24 h postoperatively. The average visual analogue scale was 2.9 and 3 (p = 0.65) in groups 1 (experimental) and 2 (control), respectively. The visual analogue scale after 1 h postoperatively was significantly lower in the erector spinae plane block group (2.3 vs. 3.3; p = 0.01). The average nalbuphine consumption was the same in both groups (46 mL vs. 47.2 mL, p = 0.69). The need for rescue analgesia was insignificantly different in both groups (group 1, 29.4; group 2, 26.4%; p = 1). The mean arterial pressure was similar in both groups postoperatively (91.8 vs. 92.5 mmHg; p = 0.63). The rate of nausea and vomiting was insignificantly different between the groups (group 1, 17.6%; group 2, 14.7%; p = 1). The median Ramsey scale in all the measurements was two. Erector spinae plane block is an effective pain treatment after percutaneous nephrolithotomy but only for a very short postoperative period.

Preemptive analgesic efficacy of ultrasound-guided transversalis fascia plane block in children undergoing inguinal herniorrhaphy: a randomized, double-blind, controlled study

Background

Surgical repair of congenital inguinal hernia results in significant postoperative discomfort and pain. The aim of the current study was to evaluate the pre-emptive analgesic efficacy of a transversalis fascia plane (TFP) block after pediatric inguinal herniorrhaphy.

Methods

Forty-four patients aged 12 to 60 months who underwent unilateral inguinal herniorrhaphy were enrolled. Four patients were excluded, and the remaining were allocated to the control group and the TFP block group. In the TFP block group, 0.4 ml/kg bupivacaine 0.25% was instilled in the plane between the transversus abdominis and transversalis fascia, while in the control group 0.9% saline was used instead of bupivacaine. The collected data were the total dose of paracetamol consumed during the first 12 h postoperatively, the postoperative Face, Leg, Activity, Cry, Consolability (FLACC) pain score, time to first use of rescue analgesia, number of patients required additional postoperative analgesics, and parents' satisfaction.

Results

The median paracetamol consumption was significantly lower in the TFP block group than in the control group, and FLACC pain scores were significantly lower for all study times in the TFP block group with higher parental satisfaction scores than those for the control group. The number of patients who required additional analgesics was significantly lower in the TFP block group than in the control group.

Conclusions

The use of a TFP block decreases postoperative analgesic consumption and postoperative pain intensity after pediatric inguinal herniorrhaphy. Future studies with larger sample size are required to evaluate the actual complications rate of TFP block.

Analgesic Efficacy of Preemptive Transversus Abdominis Plane Block in Patients Undergoing Laparoscopic Colorectal Cancer Surgery

Despite rapid advancements in laparoscopic surgical devices and techniques, pain remains a significant issue. We examined the efficacy of preemptive transversus abdominis plane (TAP) block for acute postoperative pain in patients undergoing laparoscopic colorectal cancer surgery. We retrospectively analyzed 153 patients who underwent laparoscopic colorectal cancer surgery with or without TAP block; among them, 142 were allocated to the TAP or non-TAP group. We performed between-group comparisons of demographic, clinical, and anesthetic data and pain scores at a postoperative anesthesia care unit (PACU) and at postoperative days 1, 3, and 5. There were no significant between-group differences in demographic and clinical characteristics. The mean arterial pressure, heart rate, and minimum alveolar concentration (MAC) were significantly lower in the TAP group at the start and end of surgery. The post-extubation bispectral index was significantly higher in the TAP group. There were no significant between-group differences in the pain scores and opioid consumption at the PACU or at postoperative days 1, 3, and 5, or in the time to pass flatus, the hospital stay length, and postoperative complications. Preemptive TAP block showed an intraoperative, but not postoperative, analgesic effect, characterized by a low mean arterial pressure, heart rate, and MAC.