New England Section of the American Urological Association
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Adjuvant Dexamethasone and Dexmedetomidine in Bupivacaine Penile Nerve Block during Circumcision
Wesley R. Pate, MD, Christina S. Kottooran, MD, Ricardo M. Munarriz, MD.
Boston University Medical Center, Boston, MA, USA.

BACKGROUND: Circumcision is one of the most common procedures performed by urologists in the United States. Surgeons often administer a perioperative penile nerve block with a long-acting local anesthetic to minimize pain and decrease postoperative opioid use. Recent studies in non-urologic surgical fields demonstrated that local nerve blocks combining a long-acting local anesthetic with either dexamethasone or dexmedetomidine have a faster onset and prolonged analgesia with minimal adverse effects. The purpose of this study is to evaluate the analgesic effectiveness of the addition of these adjuvant medications in penile nerve block performed during adult circumcision.
METHODS: This is a retrospective, single institution, IRB-approved study of adult male patients undergoing circumcision from January 2019 to October 2021. Patients received an intraoperative penile nerve block prior to incision with either 0.5% bupivacaine (+/- 1% lidocaine) or a combination of 0.25% bupivacaine + 70mcg dexmedetomidine + 4 mg dexamethasone. The primary outcome was maximum pain score (Analog Pain Scale) in the post-anesthesia care unit (PACU). The secondary outcomes were intraoperative and postoperative opioid use (total morphine equivalents, TME). An additional analysis was performed to control for patients with diabetes.
RESULTS: A total of 42 men (median 42 years old) underwent circumcision with a median duration of 33 minutes. Sixteen (38%) received 0.5% bupivacaine, 5 (12%) received 1:1 0.5% bupivacaine + 1% lidocaine, and 21 (50%) received the combination block. Fifteen (36%) patients had diabetes, and median hemoglobin A1c was 7.9%. Mean pain scores in PACU were not significantly different between the block groups. However, for non-diabetic patients, pain scores were significantly lower for the combination block group (0.46 vs 1.6; p<0.05). Intraoperative and postoperative opioid use was not significantly different between block groups, however, opioid use in the PACU was significantly lower in non-diabetic patients (0.7 vs 4.0 TME, p<0.01). Intraoperative bradycardia occurred in three patients, but none required intervention.
CONCLUSIONS: Intraoperative penile nerve blocks that combine long-acting local anesthetics with dexmedetomidine and dexamethasone can safely enhance immediate post-operative analgesia in non-diabetic patients undergoing circumcision. In patients with diabetes, the use of adjuvant non-opioid pain medications in the preoperative or intraoperative period may reduce opioid use postoperatively.


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