Local infiltration analgesia in urogenital prolapse surgery: a prospective randomized, double-blind, placebo-controlled study

The Effect of Preemptive Local Infiltration on Postoperative Pain After Vaginal Hysterectomy: a Retrospective Study

STUDY OBJECTIVE

To investigate the effect of preemptive infiltration on postoperative pain and the use of analgesics after vaginal hysterectomy (VH).

DESIGN

A retrospective study.

SETTING

An urogynecology unit in a tertiary medical center.

PATIENTS

A total of 120 patients who had undergone VH.

INTERVENTIONS

The study group contained 60 patients who participated in a former randomized control study, in which preemptive local infiltration of bupivacaine (n = 30) or sodium chloride 0.9% (n = 30) was performed. The control group included 60 consecutive patients who underwent a VH, for whom no local infiltration was performed.

MEASUREMENTS AND MAIN RESULTS

Postoperative pain at rest was assessed using the 10 cm visual analog scale at 3, 8, and 24 hours after surgery. The levels of pain, as well as the use of analgesics, postoperatively, were compared between the groups. The mean surgery length in the infiltration group was shorter (86.4±29 vs 118.6±30, p <.001) and the rate of posterior colporrhaphy was lower (73.1% vs 91.3%, p = .010) than the control group. There were no differences in levels of pain at all points of time. However, the infiltration group required a lower morphine dose in the recovery unit (3.7 ± 2.3 mg vs 5.3 ± 2.4 mg, p <.001) and less use of analgesia (all kinds) 24 hours after surgery (54.2% vs 79.6%, p <.001) compared with the control group. On multivariant analysis, preemptive infiltration was found to be independently inversely associated with the dose of morphine used in recovery, as well as analgesics used 24 hours after surgery.

CONCLUSION

Preemptive local infiltration of either bupivacaine or sodium chloride 0.9% reduced the use of morphine in the recovery unit, as well as the use of analgesics 24 hours after VH, compared with no infiltration at all.

Preemptive Infiltration of Local Anesthetics During Vaginal Hysterectomy: A Systematic Review and Meta-analysis of Randomized Controlled Trials

IMPORTANCE

Vaginal hysterectomy (VH) is the preferred route of choice for women desiring hysterectomy to treat uterine pathology, including premalignant conditions and fibroids.

OBJECTIVE

The aim of this study was to evaluate the impact of the use of preemptive local analgesia (LA) on postoperative pain and perioperative outcomes for women undergoing VH.

STUDY DESIGN

A systematic search of 4 electronic databases (MEDLINE, Scopus, Cochrane CENTRAL Register of Controlled Trials, and Clinicaltrials.gov ) was performed for articles published up to January 2021. All randomized controlled trials that presented outcomes of patients who underwent VH due to pelvic floor disorders or other benign gynecological disorders and received local infiltration analgesia were finally included.

RESULTS

A total of 5 studies with 277 women (138 LA group vs 199 no-LA group) who underwent a VH were included in the present meta-analysis. Mean pain scores at both 30 minutes to 2 hours and 3 to 6 hours postoperatively were significantly lower in the LA group compared with the non-LA group (220 patients: mean difference [MD], -1.75; 95% confidence interval [CI], -2.77 to -0.74; P = 0.0007; and 220 patients: MD, -1.68; 95% CI, -2.28 to 1.09; P < 0.00001, respectively). Morphine/narcotic opioid-based consumption up to 24 hours postoperatively was significantly reduced in the LA group compared with the non-LA group (197 patients MD, -9.47 mg; 95% CI, -16.51 to -2.43; P = 0.008).

CONCLUSIONS

The use of preemptive LA during VH seems to be beneficial especially with regard to short-term postoperative pain and opioid use. However, further studies are needed to identify the optimal anesthetic regimen, the dosage, and sites of application aiming to achieve the optimal benefit in the postoperative management.

The effect of preemptive local anesthesia on postoperative pain following vaginal hysterectomy: A randomized controlled trial

OBJECTIVE

We aimed to study the effect of preemptive local anesthetic without adrenaline on postoperative pain following vaginal hysterectomy and concomitant trans obturator tape (TOT).

STUDY DESIGN

This was a double-blinded, randomized, controlled trial. Women who undergone elective vaginal hysterectomy were included. Solutions of either Bupivacaine-Hydrochloride 0.5%, or Sodium-Chloride 0.9% as a placebo, were prepared prior to surgery, according to randomization. The chosen solution was injected before incision, in a circumferential manner, to the cervix. The amount of fluid administered was 10 ml. When colporrhaphy was also performed, an additional 5 ml of solution were injected in the midline of the vaginal wall prior to each incision line. We conformed to the CONSORT recommendations. By utilizing the 10 cm Visual-analogue-scale (VAS) we assessed post-operative pain at rest at 3, 8, and 24 h, and during ambulation at 8 and 24 h. We estimated that the intervention would cause a 25% reduction in the primary outcome. The required total sample size was calculated to be 30 patients women for each group. We used ANOVA for continuous variables and the Chi-square or Fisher exact tests for categorical variables.

RESULTS

A total of 30 women were included in each group. The level of postoperative pain, as assessed by VAS, was not significantly different between the groups, in all points of time. In addition, there was no difference between the groups in opioid based analgesics during recovery, nor in postoperative analgesic use.

CONCLUSION

Preemptive local anesthesia was not shown to be efficient in reducing postoperative pain after vaginal hysterectomy and TOT.

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.

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.

Implementation of enhanced recovery after surgery (ERAS) in gynaecological oncology

OBJECTIVES

To evaluate the outcomes of enhanced recovery after surgery (ERAS) implementation in a gynaecological oncology centre.

METHOD

Non-randomised control trial, evaluating morbidity outcomes, before and after implementation of ERAS programme. All consecutive major gynaecological oncology operations performed during two specified periods were included. Data were collected prospectively for a study group in the initial 7.5 months of ERAS implementation and compared with a consecutive historic control group from the exact same period, the year before. Patients' characteristics and perioperative outcomes were compared. Further analysis stratified abdominal and laparoscopic surgery.

RESULTS

In total, 265 cases identified; 99 patients followed ERAS and 99 historic controls, managed with a traditional peri-operative approach, the exact same period the year before (vulval surgery excluded, 67 cases). Groups were comparable in demographics and co-morbidities (age, BMI, ASA, WHO), level of surgery and 30 days post-operative complication (grading Clavien-Dindo classification) and readmission rates (p > 0.05). Overall, the post-operative length of hospital stay (LOS) was significantly reduced for patients who followed ERAS (4.29 ± 2.78 days versus 7.23 ± 5.68 days, p < 0.001). Stratification to subgroups was based on the type of surgery, abdominal versus laparoscopic. Those who underwent abdominal surgery and followed ERAS benefited the maximum (LOS: 5.09 ± 2.74 days versus 8.70 ± 5.75, p < 0.001) CONCLUSIONS: ERAS programme is feasible and safe in Gynae-oncology. In this study, there was a reduction of 3.61 (SE: 0.78, CI 95 %) days in the total LOS, in major abdominal Gynae-oncology surgery (level 3 and 4) without affecting complication or readmission rates.

Pain management strategies for urogynecologic surgery: a review

OBJECTIVES

The objectives of this study were to review the recent literature on surgical pain management strategies and to identify those pertinent to urogynecologic surgery.

METHODS

A literature search using Pubmed and MEDLINE was performed for trials on pain management in gynecologic surgery. Evidenced-based recommendations for preoperative, intraoperative, and postoperative pain control strategies for gynecologic procedures by various surgical routes were identified. Articles specifically describing urogynecologic procedures were sought, but quality, randomized trials on pain management modalities in other gynecologic procedures were also included.

RESULTS

Although few randomized trials on pain management strategies in urogynecologic surgery exist, quality evidence suggests that several preemptive and multimodal analgesia strategies reduce pain and opioid-related adverse events in abdominal, laparoscopic, and vaginal surgery. Evidence supporting these strategies is outlined. Many are likely applicable to urogynecologic procedures.

CONCLUSIONS

Evidence guiding pain management in specific urogynecologic procedures is sparse and should be sought in future studies. When possible, procedure-specific strategies, including preemptive and multimodal techniques, should be implemented.

Effect of high-volume systematic local infiltration analgesia in Caesarean section: a randomised, placebo-controlled trial

BACKGROUND

Pain after Caesarean section is often treated with opioids with a risk of side effects. Wound infiltration with local anaesthetics is effective and has few side effects, but volume vs. dose concentration has not been examined.

METHODS

Ninety patients scheduled for elective Caesarean section included in a randomised, double-blinded, placebo-controlled trial receiving infiltration with 50 ml ropivacaine 0.5% or 125 ml ropivacaine 0.2% or 50 ml 0.9% saline (placebo) during surgery. Surgery was performed under lumbar spinal anaesthesia. Primary endpoint was post-operative pain. Secondary endpoints were rescue analgesic, post-operative nausea and vomiting, time spent in the postanesthesia care unit (PACU) and time to first mobilisation.

RESULTS

No difference in pain response between groups, but time until maximum pain score was prolonged in the ropivacaine 0.5% group compared with the placebo group (P = 0.0493). The administration of ketobemidone at 24 h post-operatively in the ropivacaine 0.5% group was reduced compared with the placebo group (P = 0.020), and between the ropivacaine 0.2% group and the ropivacaine 0.5% group (P = 0.044). No significant differences between groups were found concerning time spent in the PACU, to first mobilisation or in number of women with nausea/vomiting (P ≥ 0.05). No complications related to ropivacaine were observed.

CONCLUSIONS

Systematic infiltration with a high concentration, low volume compared with low concentration, high volume showed no significant effect on post-operative pain intensity. However, a statistically significant, but clinically limited opioid sparing effect was demonstrated compared with placebo in the high concentration, low volume group.

Effect of systematic local infiltration analgesia on postoperative pain in vaginal hysterectomy: a randomized, placebo-controlled trial

OBJECTIVE

To assess the effect of systematic local infiltration analgesia on postoperative pain in vaginal hysterectomy, and describe the technique in detail.

DESIGN

A randomized, double-blind, placebo-controlled study following the CONSORT criteria.

SETTING

A university hospital.

PATIENTS

Thirty-seven patients undergoing vaginal hysterectomy.

METHODS

Patients received high-volume (50 mL) ropivacaine 0.50% (n = 20) or saline (n = 17) infiltration using a systematic technique ensuring uniform delivery to all tissues incised, handled or instrumented during the procedure.

MAIN OUTCOME MEASURES

Pain, nausea, vomiting and opioid requirements were assessed for 32 h as well as time spent in the post-anesthesia care unit and time to first mobilization.

RESULTS

Pain at rest was significantly reduced after one, four and eight hours in the ropivacaine group (p ≤ 0.001-0.01). Pain during coughing was significantly reduced after one and four hours (p ≤ 0.001 and p ≤ 0.003), and pain during movement was significantly reduced after four hours (p ≤ 0.02). Opioid requirements and time spent in the post-anesthesia care unit were significantly reduced in the ropivacaine group (p < 0.001 and p < 0.001, respectively), as well as the time to first mobilization (p < 0.001).

CONCLUSION

Intra-operative systematic local infiltration analgesia reduces postoperative pain in patients undergoing vaginal hysterectomy, facilities mobilization and improves early recovery.

Effect of local infiltration analgesia on post-operative pain following TVT-O: a double-blind, placebo-controlled randomized study

PURPOSE

To evaluate the effect of a protocol of local anesthesia and epinephrine associated with sedo-analgesia on post-TVT-O pain in comparison with infiltration of saline and epinephrine.

METHODS

Forty-two patients undergoing TVT-O were randomized into two groups to receive periurethral infiltration with epinephrine only (group A, n = 21) or with epinephrine plus 1 % lidocaine hydrochloride (group B, n = 21). Post-operative pain was assessed using a visual analog scale (VAS) from 0 (absence of pain) to 10 (maximum pain possible), 1, 6, 12 and 24 h after the procedure. The total amount of analgesia was recorded and the proportion of women reporting a pain VAS score ≥4, 1 h after the procedure was calculated. ANOVA for repeated measures and Bonferroni correction, the Student's t test for independent samples, the Mann-Whitney U test, the Fisher exact test, or the χ (2) test for parametric was used.

RESULTS

Pain level was significantly lower in group B 1 (p = 0.01) and 6 h (p = 0.05) after surgery, but not 12 and 24 h after the procedure. No significant difference was observed in the proportion of women requesting analgesia and in the total dosage of analgesics between the two groups. A significant higher proportion of women in group A reported a pain VAS score higher than four 1 h after surgery in comparison with patients in group B.

CONCLUSIONS

This randomized study seems to indicate that systematic infiltration before TVT-O positioning with local anesthetic may reduce immediate post-operative pain.