The use of adjuvant dexamethasone and dexmedetomidine in bupivicaine penile nerve block during penile prosthesis surgery for peri-operative analgesia
Molly E. Reissmann, MD, Michel Apoj, MD, Ricardo Munarriz, MD.
Boston University Medical Center, Boston, MA, USA.
Background:Inflatable penile prosthesis (IPP) surgery is the gold standard treatment for medication-refractory erectile dysfunction. While results are overall highly satisfactory, post-operative pain and narcotic requirement remains a concern. Use of intra-operative dorsal penile nerve block with long acting local anesthetic can improve post-operative analgesia. Recent studies in non-urologic surgical fields have demonstrated prolonged analgesia but minimal adverse effects with local nerve blocks containing long acting local anesthetic mixed with either dexamethasone or dexmedetomidine. The aim of this study was to evaluate the analgesic effectiveness of the addition of these adjuvant medications to bupivacaine penile nerve block as compared to plain bupivicaine block during primary IPP surgery.
Methods:This is a retrospective single institution IRB-approved comparative study of intraoperative dorsal penile nerve block with either plain 0.25% bupivacaine versus combination 0.25% bupivicaine + 70 mcg dexmedetomidine + 4 mg dexamethasone in patients undergoing primary IPP surgery (December 2019 to 2020). The primary outcome was pain level (Analog Pain Scale) throughout the first 24 hours post-operatively (PACU arrival, 2, 6, 12, 18, and 24 hours post operatively). The secondary outcome measures were intra- and post-operative narcotic consumption (total morphine equivalents, TME).
Results:62 patients (mean age 60.5 years) were included in the study. 32 received plain bupivacaine, whereas 30 received the combination block. Mean pain levels in PACU, 2 hours, and 12 hours post-operatively were significantly lower in the combination block group (0 vs 4; 1 vs 5; 3 vs 5.5; p<0.05). Mean total narcotic consumption (TME) was lower for the combination block (42 vs 65, P<0.05). There was no significant difference in the intraoperative narcotic administered between the treatment groups. Two patients who received the combination block had intraoperative bradycardia but did not require intervention.
Conclusion: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.
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