Pediatr Surg Int (2007) 23:49–55 DOI 10.1007/s00383-006-1815-4

O R I G I N A L A RT I C L E

Elective orchidopexy in the paediatric population: a trial of intra-operative spermatic cord block A. H. Blatt Æ J. G. Cassey

Accepted: 25 September 2006 / Published online: 20 October 2006
Springer-Verlag 2006

Abstract It is well established that pre-emptive and multimodal analgesia improve pain control and decrease narcotic use as well as the length of stay. Whilst some form of local anaesthetic (LA) block is almost routine for most inguinal procedures in children, the best modality is uncertain for orchidopexy. We sought to explore as to whether the addition of spermatic cord block (SCB) to our standard ilio-inguinal block (IIB) in this situation had any impact on analgesic requirements post-operatively. A retrospective review of a single surgeon and single centre experience of LA block for elective orchidopexy is described for a 9-year period. In the first half of the study, the LA technique was an IIB. An SCB was added to the IIB in the second half using the same total dose of 0.8 ml/kg bupivacaine. In the entire group, 35% of the SCB + IIB boys required narcotics as compared to 56% with IIB alone (p > 0.05). On subgroup analysis of a ‘‘medium risk’’ procedure (i.e. inguinal approach for a superficial pouch testis) only 35% required narcotics in the SCB + IIB group as compared to 70% in the IIB (p < 0.05). Use of a SCB + IIB in elective orchidopexy in a paediatric population has additional benefit to IIB alone.

A. H. Blatt Department of Urology, John Hunter Hospital, Newcastle, NSW, Australia J. G. Cassey Department of Paediatric Surgery, John Hunter Hospital and Warners Bay Private Hospital, Newcastle, NSW, Australia A. H. Blatt (&) 703/8 Glen St, Milsons Point 2061 NSW, Australia e-mail: [email protected]

Keywords Orchidopexy
Spermatic cord block
Ilio-inguinal block
Post-operative pain

Introduction Effective pain management in paediatric surgery is essential to the recovery and emotional well-being of the patient and family. Post-surgical pain management has improved dramatically over the past 10 years with the application of new routes of administration, newer agents, and the recognition and development of multimodal and pre-emptive analgesia [1–3]. Children experience pain to the same degree as adults and the treatment modalities used in the adults are also available to children [1, 4]. Even patient-controlled analgesia techniques have been used successfully in patients as young as 5 years old [5, 6]. Regional analgesia has been very successful in paediatric surgery and has particularly been established in elective circumcision [7, 8]. It is now commonplace for day-stay paediatric surgical procedures, where ilioinguinal blocks (IIBs) are frequently employed [9–11]. Spermatic cord blocks (SCB) have been previously described in adults as efficacious, safe and cost-effective [12–14]. Dissatisfaction with the effectiveness of IIB for orchidopexy prompted a trial of the SCB technique. We now review as to whether the addition of SCB in orchidopexy had any impact on analgesic requirements postoperatively. Methods We retrospectively reviewed the use of post-operative analgesia in children having orchidopexy by a single

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surgeon (JGC) in a single private hospital between May 1996 and March 2005. The study period was chosen as it reflected a time when the anaesthetists (and anaesthetic technique) and recovery staff (and policies) were consistent in this hospital. In the first part of the study period (to October 2001) orchidopexy was accompanied by an IIB with bupivacaine 0.25% (maximum 0.8 ml/kg). In the second half (November 2001–March 2005), the same solution and exactly the same total dose were used to perform an SCB block in addition to the IIB. Neither the surgical nor anaesthetic techniques were otherwise altered over this period. Patients were admitted to the children’s day-stay unit prior to theatre. An oral pre-med was administered at the discretion of the anaesthetist (paracetamol 20 mg/kg). Anaesthesia was administered using a gaseous induction and maintained by spontaneous ventilation. It is important to note that narcotics were never given as a pre-med but were administered intra-operatively at the discretion of the anaesthetist. Orchidopexy was performed either through an inguinal or scrotal approach [15] and all children (including those with impalpable testes) are included in this review. After induction of anaesthesia, the inguinal and scrotal wounds were infiltrated separately, as was the raphe at the site of the scrotal fixation. After skin incision, all blocks were then performed by the surgeon. Using the inguinal approach, the technique of IIB used was by infiltrating with local anaesthetic (LA) beneath the external oblique aponeurosis under direct vision. In the patients having a scrotal approach, the technique was modified so that the external oblique was punctured ‘‘blindly’’, medial to the anterior-superior iliac spine. In those patients who also had an SCB, this followed the IIB as soon as the spermatic cord was delivered

Fig. 1 Technique of spermatic cord block: a holding the cord taut and avoiding obvious vessels with the needle, b raising a bleb within the cord

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into the wound—generally within a few minutes of the IIB. The spermatic cord was exposed either at the external ring (scrotal orchidopexy) or within the inguinal canal after opening the external oblique (inguinal orchidopexy). The processus vaginalis was then opened anteriorly and the incision was continued towards the internal ring in the line of the cord. The length of this incision was determined by the operative findings. Holding the cord taut, the retroperitoneal plane was entered with a 25 or 30 G needle (depending on the patient size) and passed through the posterior portion of the sac, immediately above the cord structures (Fig. 1). Obvious blood vessels were avoided. Raising a small blister within the spermatic cord and then increasing the injected volume slowly gave the most uniform result. We aimed to have no vessels visible beneath the peritoneum across the entire cord at that level. The orchidopexy procedure then continued as usual. In the patients having a scrotal approach, the technique was modified in that the external oblique was not opened. Post-operatively, the parents were brought to Recovery as soon as their child’s physiological state was determined to be normal and stable, usually prior to waking. Post-operative analgesia was given as required and according to a standard protocol. This consisted of: paracetamol 20 mg/kg once and 15 mg/kg every 4 h thereafter with a maximum of 90 mg/kg/day. It was given orally or rectally (if the patient had nausea or vomiting). The alternative oral option was ibuprofen (10 mg/kg). Intravenous narcotics (morphine 0.01 mg/ kg or pethidine 0.1 mg/kg) were given incrementally if oral analgesia was insufficient. The same pool of four experienced paediatric recovery staff looked after all the children. The children were transferred back to the day-stay unit when fully conscious and comfortable. The same

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analgesics were available in the day-stay unit. Free fluids were permitted in Recovery and free diet in the day-stay unit. Standard demographic data were collected as well as the position of the testis, unilateral or bilateral, previous orchidopexy, operative factors (inguinal or scrotal approach and ‘‘difficult’’ procedures) and analgesia requirements. The data were analysed for the entire group and then by subgroups based on the predicted risk of requiring narcotics (Table 1). The detailed operation reports were used to allocate boys to the following risk categories: ‘‘High’’—high testis, including intraabdominal, requiring considerable retroperitoneal dissection and with a tight or moderately tight cord before fixation; ‘‘Medium’’—inguinal testis in the superficial inguinal pouch, cord tension not tight; ‘‘Low’’—scrotal approach, testis able to be brought into upper scrotum by intra-operative traction and testis below level of scrotum before fixation. Data were analysed using Chisquare and the Fisher exact test.

Results Over an 8.8-year period, 89 boys underwent elective orchidopexy. Forty-eight of these patients received an SCB intra-operatively in addition to an IIB. The patient characteristics were similar in both the groups (Table 2). There was no difference in the proportion of patients who required some form of analgesia postoperatively. Eleven of the IIB group and 12 of the SCB + IIB group received non-narcotic analgesia postoperatively. Only 35% (17/48) of the SCB + IIB boys required narcotics at some stage (pre-, intra- or postoperatively), as compared to 56% (23/41) of the IIB group, although the difference did not reach statistical significance. The narcotic requirement was analysed separately according to a risk group. The medium risk group showed a significant difference between the types of blocks used and numbers not requiring any narcotics at anytime (Table 3). In this subgroup, only 35% required Table 1 Risk groups Description High Medium Low

Inguinal approach with high testis (including intra-abdominal) Inguinal approach with testis in superficial inguinal pouch Scrotal approach

51 Table 2 Patient baseline characteristics

Number of patients Age mean (years) Unilateral operation Bilateral operation Inguinal approach Scrotal approach

SCB + IIB

IIB alone

48 5.3 45 3 31 17

41 5.4 32 9 21 20

Table 3 Narcotic use according to risk group Block type

Low risk

Medium risk

High risk

Total

SCB + IIB IIB

27 (4/15) 44 (8/18)

30 (7/23) 63 (10/16)

60 (6/10) 71 (5/7)

35 (17/48) 56 (23/41)

Figures are expressed as a percentage (number of boys requiring narcotics/total number of boys in risk group)

narcotics in the SCB + IIB group as compared to 70% in the IIB (p < 0.01). The majority of narcotic use was seen in the postoperative period (Table 4). However, intra-operative narcotic was given at the discretion of the anaesthetist. This constituted six patients (12.5%) in the SCB group and 11 (27%) in the IIB group. The intra-operative narcotic administration in no way altered the postoperative analgesic protocol followed in Recovery. Only three patients who received intra-operative narcotic also received narcotic post-operatively (Table 4). Two of these patients were in the high-risk group and one in the low-risk group. The total narcotic doses obviously varied according to the patient needs. In the IIB group morphine was the narcotic of choice in 17 of the 23 who received narcotics. The total morphine doses ranged from 0.02 to 0.18 mg/kg (mean 0.07; median 0.05). Six of the IIB group received pethidine with a dose range of 0.11–0.41 mg/kg (mean 0.25; median 0.27). In the SCB group, of the 17 who received narcotic six had morphine (range 0.02–0.06; mean 0.04; median 0.03), eight

Table 4 Timing of narcotics

SCB + IIB Intra-operative Post-operative IIB Intra-operative Post-operative

Low risk

Medium risk

High risk

Total

4/15 1/15 4/15 8/18 6/18 2/18

7/23 2/23 5/23 10/16 2/16 8/16

6/10 3/10 5/10 5/7 3/7 2/7

17/48 6/48 14/48 23/41 11/41 12/41

Figures are expressed as numbers of boys requiring narcotics/ total number of boys in risk group

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had pethidine (range 0.21–0.75; mean 0.44; median 0.43), one had fentanyl (0.94 mg/kg), and two had a combination (morphine/pethidine at 0.05/0.13 mg/kg and fentanyl/pethidine at 0.37/0.19 mg/kg). There was no difference between the two groups with respect to the time of discharge (mean 2.4 h, range 1.3–7 h). There were no operative or postoperative complications of the LA blocks in either group.

Discussion Despite the magnitude of effects that acute pain can have on a child, it is often inadequately assessed and treated [1, 4]. The American Pain Society recommendations for management of acute paediatric pain emphasise that the key to managing procedure-related pain is anticipation. Opportunities for alleviating pain exist before, during and after the procedures, and many interventions are effective. The treatment should be multimodal and meet the child’s needs. Techniques should include non-pharmacological methods such as behavioural strategies, complementary approaches, a quiet environment, calm adults, and clear, confident instructions [1]. This is the first study looking specifically at the benefit of SCB in a paediatric population. We have demonstrated that an intra-operative SCB in combination with IIB decreases narcotic requirements in the paediatric patients undergoing elective orchidopexy, in particular those requiring a standard inguinal procedure for a testis in the superficial inguinal pouch. In retrospective and survey studies, we believe that analysing the analgesic medication administered is a reasonable representation of pain requirements. In our study, the use of other analgesics was not altered by the block type. This confirms the consistent approach by staff to analgesic assessment and administration, i.e. they did not simply swap narcotics for oral analgesia. Better measures of pain control, which can be utilised in prospective studies are visual analogue scales (VAS), facial expression scale, numeric rating scales (NRS) and verbal assessment correlated with the VAS [16]. Multiple prospective paediatric studies have successfully validated these scales [5, 11]. We did not demonstrate an overall decreased narcotic use in the SCB patients. The difference was only significant in the medium-risk group. There are both statistical and procedural reasons as to why we may have missed a ‘‘real’’ overall difference. The Chisquare value was 3.82—with significance at the 0.05 level requiring a Chi-square of ‡ 3.84. We may simply

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have had too small an overall sample to adequately demonstrate a true benefit, or too small a sample within the individual subgroups, i.e. the difference between IIB and IIB + SCB may be small in the lowrisk group (scrotal approach) where there is less dissection; whereas, in the high-risk group (with intraabdominal dissection of a high testis) adding SCB may still be inadequate for complete analgesia. Results may also have been affected by a possible learning curve in the surgical technique, even in high-risk patients. There is a trend in our data suggesting this is the case: of the last 12 cases (eight of whom had medium or high risk), none had any narcotics. We did not demonstrate improved time to discharge. This may reflect low numbers again or other multiple factors including logistical (awaiting review by surgeon prior to discharge), social (transport pre-arranged) or patient related (e.g. nausea). The time to discharge is a poor surrogate for analgesic efficacy. It was anticipated that with decreased use of narcotics we might demonstrate decreased side effects, especially vomiting. In this retrospective study, the true incidence of nausea and vomiting is probably underreported. There was a very low incidence of antiemetic use in both groups. This is a retrospective study analysing patients after a change in intra-operative analgesic protocol. The potential sources of error or bias are acknowledged. We attempted to minimise these by having consistency in surgeon, anaesthetists, recovery staff, medical centre and protocols for assessment and management of postoperative children. The recovery staff were unaware of a change in surgical protocol but could presumably have deduced this from the operation report. This seems unlikely since the only ‘‘recovery relevant’’ information was whether they had a LA block, not what type. In addition, narcotic use was still prevalent in recovery following introduction of the SCB and the staff were experienced and consistent. A possible criticism is that the use of narcotic postoperatively may have changed over time. During the time period, and currently, it has been both the policy and practice of the anaesthetists and recovery staff in this institution to encourage free use of narcotics for pain in the post-operative period. Since all the recovery staff had worked with children for many years, were well accustomed to assessing and managing postoperative distress and pain, and were familiar with the expected outcomes from orchidopexy, we feel it unlikely that any significant changes to their practice would have influenced the results. Similarly, neither the indications for surgery nor the selection and technique of exploration/orchidopexy changed over

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this period, apart from the choice of the LA block itself. It could be argued that our allocation of patients to the different risk groups was a fairly broad classification. It is acknowledged that there are many factors influencing post-operative pain apart from the operative approach and position of the testis. However, experience suggests that those boys requiring more retroperitoneal dissection and with tight spermatic cords have more post-operative pain than those with easier dissections. Also, the final length of the spermatic cord prior to fixation can vary from lax to quite tight. It has been JC’s practice to write a standardised operation report with particular reference, amongst other things, to position, difficulty of dissection, whether extensive retroperitoneal dissection was required and assessment of final cord length (laxity). The stratification of patients into three subgroups for probability of post-operative narcotic use was not arbitrary but based on this prospectively collected detailed intra-operative data and patients were allocated to these subgroups prior to any analysis of the results. Therefore, this stratification was not a potential source of selection bias in the authors’ view. The total narcotic doses and the types of narcotics varied among both patient groups, as can be expected in a retrospective study. For this reason the analysis focussed on the total number of patients receiving narcotics rather than dose scales. Obviously this makes it impossible to detect minor differences in the two groups’ requirements as well as on risk subgroup analysis. If anything however we would expect this to decrease rather than increase the SCB effect as it may be that total narcotic requirement itself was minimised in these patients. Obviously this is a matter of debate and cannot be answered by the present study. The SCB was given a short time after the IIB and it could be argued that it therefore lasted longer postoperatively and accounted for any observed improvement in narcotic consumption. However, this argument is counteracted by the large body of evidence supporting pre-emptive analgesia. It is also important to note that the SCB had only received half of their dose of bupivacaine during this short delay and may have had less pain control during this period of dissection. Arguments either way are unhelpful as the delay was short (exposure of the cord as shown in Fig. 1) and the outcomes are what is important. Unlike SCB, the benefit of IIB in inguino-scrotal surgery has been well established in the paediatric literature, predominantly for inguinal herniotomy (IH) rather than orchidopexy [9, 10]. Shandling performed percutaneous IIB (blind injection medial to the ante-

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rior superior iliac crest) on 81 boys undergoing IH and found a reduction in general anaesthetic requirements and post-operative analgesics as compared to nonrandomised controls [9]. A randomised blinded control trial with 99 patients followed and demonstrated significantly reduced codeine and general post-operative analgesics in hospital, as well as decreased acetaminophen requirements at home [10]. Activity levels immediately post-operatively and at 48 h were also improved in the IIB group [10]. Casey randomised boys undergoing IH to either open IIB or LA wound irrigation for 2 min prior to wound closure. He found no significant difference between the two groups’ pain, analgesia, recovery or discharge times [11]. Risks of IIB are inadvertent intra-vascular or intra-peritoneal injection and poor placement of LA resulting in insufficient analgesia. Furthermore, cases of transient quadriceps muscle paresis have been reported after these nerve blocks [16]. Alleviation of post-operative pain in boys undergoing orchidopexy has been addressed by a number of clinical trials in children. Unfortunately, many of these studies combine IH, hydrocele correction and orchidopexy with no attempt to separate the responses [17– 19]. However, these combined studies provide some useful information. Shenfield studied 90 boys undergoing orchidopexy or IH comparing LA wound irrigation with saline [17]. Post-operative analgesic use and vomiting were decreased in the LA group. Again combining IH and orchidopexy in 41 patients, Cross found no difference between IIB or caudal block in duration or quality of analgesia, vomiting or delayed micturition [18]. Markham also included hydrocele correction with IH and orchidopexy in his randomised trial comparing IIB to caudal block in 52 boys. Again no significant difference was found between IIB and caudal block in pain, analgesic use or complications [19]. Looking specifically at regional anaesthesia for orchidopexy, some studies suggest a superiority of caudal block over IIB (without the addition of SCB) [20, 21]. Somri measured plasma catecholamines in 30 boys randomised to IIB or caudal block for orchidopexy [20]. Considering these hormones as an objective surrogate for pain and anxiety, significantly lower levels were found in the caudal group post-operatively. They did not specifically measure post-operative pain. In a further comparison of IIB to caudal block in orchidopexy, Findlow’s randomised trial of 40 boys found caudal block superior to IIB in both duration of analgesia and amount of analgesic required [21]. Comparing caudal block to IIB, Stow measured plasma bupivacaine concentrations and found that uptake was

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more rapid after IIB and reached a higher mean peak concentration. However the concentrations were well below potentially toxic levels [22]. Despite the possible advantages of caudal block, the disadvantages include; more time-consuming than IIB; paraesthesia in the lower extremities (or inability to walk) in some children; urinary retention in older children; higher dose of LA required than IIB; inadvertent intra-vascular injection; and haematoma [11, 18–20]. In the adult population, several studies have demonstrated the benefit of SCB in inguino-scrotal surgery [12–14, 23]. There are various methods described in the literature for a SCB in adults. The most common techniques are percutaneous pre-operative injections either lateral to the pubic tubercle overlying the external inguinal ring, or injecting after grasping the scrotum and cord at the external ring [13, 14, 23]. These blind techniques have obvious disadvantages of both missing the target and causing inadvertent injury, particularly to vessels. They have a particular role in adult day case surgery, where supplementary anaesthesia is often not given. However, they have less application for paediatric surgery where operating solely under LA is rare. Less commonly described is a technique similar to our own, of intra-operative local anaesthesia infiltrated directly into the cord under vision with the patient under some form of general anaesthesia [12]. The only published randomised control trial for SCB in adults demonstrated improved pain control in the immediate recovery period [12]. In the 48 patients studied undergoing general anaesthetic day-case testicular surgery, prolonged improvement in pain control over controls was not demonstrated. It may be noted that the open technique of SCB in this study was performed at completion of the operation, thus negating any potential pre-emptive benefit. Two large prospective studies have also demonstrated the safety and efficacy of SCB in adults. Wakefield performed percutaneous injection of LA over the external ring in 103 patients undergoing inguino-scrotal surgery as a daycase procedure [14]. The patients tolerated the procedure well and there were no complications related to the block. Issa performed bilateral simple orchidectomy on 141 patients using bilateral SCB alone [13]. This was done by grasping the cord at the external ring and injecting LA percutaneously. Patients rated their pain as being at its worst during the actual injection with a visual analogue score for the intra-operative pain averaging only 1.96 of 10. Ninety-two per cent of patients were ‘‘highly satisfied’’ with the procedure. When choosing from the available modalities for post-operative pain control for elective paediatric

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orchidopexy, our results suggest benefit is gained in adding SCB to an IIB in standard inguinal orchidopexies. This needs to be evaluated in a prospective fashion and may prove to benefit a wider range of paediatric patients. The technique has clear advantages over all other modalities.

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Pediatr Surg Int (2007) 23:49–55 18. Cross GD, Barrett RF (1987) Comparison of two regional techniques for postoperative analgesia in children following herniotomy and orchidopexy. Anaesthesia 42:845 19. Markham SJ, Tomlinson J, Hain WR (1986) Ilioinguinal nerve block in children. A comparison with caudal block for intra and postoperative analgesia. Anaesthesia 41:1098 20. Somri M, Gaitini LA, Vaida SJ, et al (2002) Effect of ilioinguinal nerve block on the catecholamine plasma levels in orchidopexy: comparison with caudal epidural block. Paediatr Anaesth 12(9):791–797

55 21. Findlow D, Aldridge LM, Doyle E (1997) Comparison of caudal block using bupivacaine and ketamine with ilioinguinal nerve block for orchidopexy in children. Anaesthesia 52(11):1110–1113 22. Stow PJ, Scott A, Phillips A, et al (1988) Plasma bupivacaine concentrations during caudal analgesia and ilioinguinal-iliohypogastric nerve block in children. Anaesthesia 43(8):650– 653 23. Kaye KW, Lange PH, Fraley EE (1982) Spermatic cord block in urologic surgey. J Urol 128(4):720–721

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