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OBJECTIVES: Continuous wound infiltration of local anesthetics has been proposed as an alternative to epidural analgesia during abdominal surgery. Cytokines have a major role in inflammatory changes caused by surgery. This study aimed to compare the effects of continuous preperitoneal versus epidural analgesia on inflammatory cytokines postoperatively. MATERIALS AND METHODS: Forty patients scheduled for radical cystectomy were included in this observer-blinded, randomized trial; patients were randomly assigned into 2 groups to receive; continuous preperitoneal wound infiltration (PPB) or epidural analgesia (EDB). Serum levels of interleukins (IL1ß, IL6, IL10, and tumor necrosis factor α) were measured at baseline (before induction of anesthesia), preinfusion (before the start of local anesthetic infusion), 6 and 24 hours postoperatively. Visual Analog Scale at rest/movement (VAS-R/M), time to the first request of analgesia, total morphine consumption, sedation score, hemodynamics, and side effects were observed 24 hours postoperatively. RESULTS: There was a significant reduction in IL6, IL1ß and increase in IL10 in PPB compared with EDB at 6 and 24 hours postoperatively and compared with preinfusion levels (P≤0.001). In EDB, a significant increase in IL1ß, IL10, and tumor necrosis factor α at 6 hours compared with preinfusion levels (P≤0.002). VAS-R/M was significantly decreased at 2, 4, 6, 8, and 12 hours in EDB compared with PPB (P≤0.014), with no significant difference in the mean time to the first request of analgesia and total morphine consumption between the 2 groups. CONCLUSION: Continuous preperitoneal analgesia better attenuated postoperative inflammatory response and provided a comparable overall analgesia to that with continuous epidural analgesia following radical cystectomy.

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STUDY OBJECTIVE: The objective of this study was to evaluate the effect of adding dexmedetomidine (DEX) to bupivacaine on the quality of spermatic cord block anesthesia and postoperative analgesia. DESIGN: This is a randomized, double-blind study. SETTING: This study was performed in an educational and research hospital. PATIENTS: One hundred twenty adult males were scheduled for intrascrotal surgeries. INTERVENTIONS: Patients were divided into two groups: group B received 10 mL of bupivacaine 0.25% for spermatic cord block and intravenous 50 µg of DEX and group BD received 10 mL of bupivacaine 0.25% added to 50 µg of DEX (9.5 mL bupivacaine 0. 25% + 0.5 mL [50 µg] DEX) for spermatic cord block, and for masking purposes, the patients received isotonic saline intravenously. MEASUREMENTS: Time to first analgesic request, analgesic consumption, and visual analog scale (VAS) pain score in the first 24 hours postoperatively were assessed. MAIN RESULTS: Time to first rescue analgesic was significantly delayed in group BD in comparison with group B, median (interquartile) range, 7 (6-12) hours versus 6 (5-7) hours, (p=0.000), the mean cumulative morphine consumption (mg) in the first postoperative 24 hours was significantly lower in group BD compared with group B, 8.13±4.45 versus 12.7±3.79, with a mean difference (95% CI) of -4.57 (-6.06 to -3.07) (p=0.000); also, there was a significant reduction of VAS pain score in group BD in comparison with group B at all measured time points, VAS 2 hours (1.28±0.9 vs 1.92±0.8), VAS 6 hours (2.62±1.5 vs 3.93±1.2), VAS 12 hours (2.40±1.1 vs 3.57±0.65), VAS 24 hours (1.90±0.68 vs 2.53±0.62) (p=0.000). CONCLUSION: The addition of 50 µg of DEX to bupivacaine 0.25% in spermatic cord block for intrascrotal surgeries resulted in delay of first analgesic supplementation, reduction of postoperative analgesic consumption as well as improvement of the success rate of the block.

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BACKGROUND: The superior hypogastric plexus (SHGP) carries afferents from the viscera of the lower abdomen and pelvis. Neurolytic block of this plexus is used for reducing pain resulting from malignancy in these organs. The ganglion impar (GI) innervats the perineum, distal rectum, anus, distal urethra, vulva, and distal third of the vagina. Different approaches to the ganglion impar neurolysis have been described in the literature. OBJECTIVES: To assess the feasibility, safety, and efficacy of combining the block of the SHGP through the postero-median transdiscal approach with the GI block by the trans-sacro-coccygeal approach for relief of pelvic and/or perineal pain caused by pelvic and/or perineal malignancies or any cancer related causes. METHODS: Fifteen patients who had cancer-related pelvic pain, perineal pain, or both received a combined SHGP neurolytic block through the postero-median transdiscal approach using a 20-gauge Chiba needle and injection of 10 mL of 10% phenol in saline plus a GI neurolytic block by the trans-sacro-coccygeal approach using a 22-gauge 5 cm needle and injection of 4 - 6 mL of 8% phenol in saline. Pain intensity (measured using a visual analogue scale) and oral morphine consumption pre- and post-procedure were measured. RESULTS: All patients presented with cancer-related pelvic, perineal, or pelviperineal pain. Pain scores were reduced from a mean (± SD) of 7.87 ± 1.19 pre-procedurally to 2.40 ± 2.10 one week post-procedurally (P < 0.05). In addition, the mean consumption of morphine (delivered via 30 mg sustained-release morphine tablets) was reduced from 98.00 ± 34.89 mg to 32.00 ± 28.48 mg after one week (P < 0.05). No complications or serious side effects were encountered during or after the block. LIMITATIONS: This study is limited by its small sample size and non-randomized study. CONCLUSION: A combined neurolytic SHGP block with GI block is an effective and safe technique for reducing pain in cancer patients presented with pelvic and/or perineal pain. Also, a combined SHGP block through a posteromedian transdiscal approach with a GI block through a trans-sacrococcygeal approach may be considered more effective and easier to perform than the recently invented bilateral inferior hypogastric plexus neurolysis through a transsacral approach.

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