Abstract
Background
The efficacy of dorsal penile nerve block versus caudal block among children undergoing circumcision has been studied in several trials with conflicting results. We aimed to perform an updated systematic review and meta-analysis comparing both techniques in children undergoing circumcision under general anesthesia.
Methods
MEDLINE, Embase, and Cochrane Library were systematically searched for studies comparing dorsal penile nerve block versus caudal block in children undergoing circumcision. We computed mean differences (MD) or standardized mean difference (SMD) for continuous outcomes and risk ratios (RR) for binary outcomes, with 95 % confidence intervals (CIs). Heterogeneity was assessed using I 2 statistics. Statistical analyses were performed using R Software, version 4.2.3.
Results
We included 14 studies, comprising 1425 participants, of whom 645 (45.3 %) underwent dorsal penile nerve block. There were no significant differences between groups in time to first analgesic requirement (MD -14.79 min; 95 % CI -59.42 to 29.83; p = 0.52), and postoperative pain at 1h (SMD 0.10; 95 % CI -0.60 to 0.79; p = 0.79), 3h (SMD 0.00; 95 % CI -0.98 to 0.99; p = 0.99), and 24h (SMD 0.30; 95 % CI -2.57 to 3.17; p = 0.84). Dorsal penile nerve block was associated with a shorter time to first walk (MD -30.28 min; 95 % CI -44.50 to −16.05; p < 0.01) and length of hospital stay (MD -28.61 min; 95 % CI -42.13 to −15.10; p < 0.01).
Conclusions
In children undergoing circumcision, dorsal penile nerve block and caudal block had similar times to first rescue analgesic and postoperative pain scores within 24h, although dorsal penile nerve block was associated with a shorter time to first walk and length of hospital stay.
Highlights
- •
Circumcision is a common surgical procedure in pediatric patients.
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It is associated with moderate to severe intraoperative and postoperative pain.
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Regional anesthesia is often combined with general anesthesia, for multimodal pain management.
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Dorsal penile nerve block may offer advantages over neuraxial blocks reducing ambulation time and hospital stay.
1
Introduction
Circumcision is a surgical procedure commonly performed in pediatric patients [ , ]. It is associated with moderate to severe intra and postoperative pain, and usually performed under general anesthesia (GA) [ ]. GA is often implemented with regional analgesia, an essential component of a multimodal pain control regimen [ ]. Caudal block (CB) is a central neuraxial block, widely utilized in the pediatric population due to its ease of learning and high success rate [ ]. CB is known to involve hemodynamic/systemic or local adverse events, such as arrhythmia and hypotension when combined with GA, respiratory depression resulting from total spinal block by inadvertent dural puncture, toxicity-related seizures, infection/inflammation of the puncture site, sacral osteomyelitis, or local nerve injury [ ]. However, previous meta-analysis showed controversial results regarding the incidence of urethral fistula or other complications [ ].
Dorsal penile nerve block (DPNB) was proposed as a simple and equally effective alternative for postoperative analgesia control in pediatric patients undergoing circumcision [ ]. Traditionally, DPNB is based on landmark orientation in which the local anesthetic (LA) is injected through the skin below the pubic bone at the base of the penis [ ]. As a peripheral nerve block, DPNB can provide longer-lasting analgesia using smaller volumes of LA targeted specifically to the surgery site, thereby avoiding most of the adverse events associated with CB [ ]. However, DPNB carries risks such as local hematoma or an incomplete block, and both techniques can cause local anesthetic systemic toxicity [ ].
Previous meta-analyses comparing CB versus other methods of analgesia in pediatric circumcision have been performed, showing that both CB and DPNB provide effective analgesia [ ]. However, their analyses included trials published up until 2008 and since then, new studies comparing CB and DPNB in pediatric patients undergoing circumcision have been published, and there remains uncertainty about the best approach. Therefore, we aimed to perform an updated systematic review and meta-analysis comparing CB to DPNB in pediatric patients undergoing circumcision, observing whether there is a practical benefit or not from the DPNB.
2
Material and methods
This systematic review and meta-analysis was conducted following Cochrane recommendations and Preferred Reporting Items for Systematic Review and Meta-Analyses (PRISMA) guidelines [ , ]. The protocol for this study was prospectively registered in the International Prospective Register of Systematic Reviews (PROSPERO) database under protocol number CRD42024514053.
2.1
Eligibility criteria
We restricted inclusion to the following criteria: (1) randomized controlled trials (RCTs) and observational studies that recruited pediatric patients between 0 and 18 years of age, American Society of Anesthesiology (ASA) physical status classes I-II (2) enrolling patients undergoing circumcision, (3) comparing DPNB with CB, and (4) reporting at least one outcome of interest. We excluded: (1) studies that recruited preterm infants or adults, (2) studies with children undergoing surgeries other than circumcision, (3) studies in which surgery was performed under sole local or regional anesthesia, or (4) studies where regional analgesia was delivered with LA mixed with adjuvants, including epinephrine, steroids, opioids, alpha-adrenergic agonists, ketamine or benzodiazepines.
2.2
Search strategy and data extraction
We systematically searched MEDLINE, Embase, and Cochrane Library databases from inception to February 2024. Google Scholar was not included in our search strategy. The following search terms were used: “circumcision”, “penile surgery”, “posthectomy”, “caudal”, “dorsal penile nerve block”, “DPNB”, and “block”. No language restrictions were used. We further performed a backward snowballing search using references from included studies and previous systematic reviews [ ].
Data were independently extracted by two authors (R.F. and M.C.), following predefined search criteria. A template was developed for data extraction of relevant items, including study details (author, year of publication, study design, sample size, and time of follow-up), participants (population characteristics, weight, sex, ASA physical status), intervention, control, and outcome measures.
2.3
Endpoints and subgroups analysis
The primary outcomes were time to first analgesic requirement and postoperative pain scores at 1, 3, and 24 h post block. Secondary outcomes included the incidence of postoperative nausea and vomiting (PONV), time to first micturition, motor block incidence, time to first walk, and postanesthetic care unit (PACU) and hospital length of stay. Postoperative pain was measured using the standard mean difference (SMD), as different scales were used across trials: Children’s Hospital of Eastern Ontario Pain (CHEOPS) [ ]; Face, Legs, Activity, Cry and Consolability (FLACC) scale [ ]; Wong-Baker Faces Pain Rating, and Faces Pain Rating (FPRS) [ ]. These outcomes were selected for their direct relevance to clinical practice, focusing on pain control, block duration, and safety profiles, as these factors impact both short-term recovery and long-term well-being of pediatric patients.
Subgroup analyses were performed for the primary outcomes to assess any statistical difference between RCTs and observational trials.
2.4
Risk of bias assessment
Two authors (M.C. and E.P.) independently assessed the risk of bias. Disagreements were resolved with a third author (S.A.). RCTs were appraised with the Cochrane Collaboration’s tool for assessing risk of bias in randomized trials (RoB-2), with 5 domains: selection, performance, detection, attrition, and reporting [ ]. The Risk Of Bias in Non-randomized Studies of Interventions (ROBINS-I) tool was used to evaluate the cohort studies, with 7 domains: confounding, selection of participants, classification of interventions, deviations from intended interventions, missing data, measurement of outcomes, and reported result [ ].
The risk of publication bias could not be assessed by funnel plot analysis or Egger’s regression test due to the small number of studies included in each individual outcome. Despite the number of included studies in the meta-analysis, there were no outcomes with data from ≥10 individual studies [ ].
The quality of evidence for each finding was rated based on criteria established by the Grading of Recommendations Assessment, Development and Evaluation (GRADE) group [ ]. RCTs were considered to be of high-quality evidence, which could be downgraded to moderate, low, or very low quality for five reasons (high risk of bias, inconsistent results, indirect evidence, imprecision, and publication bias). Disagreements were settled by consensus.
2.5
Sensitivity analyses
We performed leave-one-out sensitivity analyses for the primary outcomes to assess the effects of influential studies on the pooled analysis. Studies were sequentially removed and the data were reanalyzed to ensure the stability of the pooled effects.
2.6
Statistical analysis
We pooled risk ratio (RR) and mean difference (MD) or SMD with 95 % CI for categorical and continuous outcomes, respectively. DerSimonian and Laird random-effects models were employed for all endpoints due to the heterogeneity in methodology and demographics across the individual studies [ ]. We assessed heterogeneity with I 2 statistics and Cochran Q test; p-values <0.10 and I 2 >40 % were considered significant for heterogeneity. Statistical analyses were performed using R Software, version 4.2.3 (R Foundation for Statistical Computing).
3
Results
3.1
Study selection and characteristics
The initial search yielded 1987 results on February 18, 2024. After removing duplicate results and applying the eligibility criteria, 60 studies were selected for full-text review, as detailed in Fig. 1 . Of these, 14 studies were included in this systematic review and meta-analysis [ ]. The main reasons for exclusion were studies comparing other types of regional anesthesia (e.g. pudendal block) or the wrong population (e.g. children undergoing other types of surgery).
A total of 1425 participants were included, of whom 645 (45.3 %) were selected to undergo DPNB. Mean age of patients ranged from 3 to 12.5 years and mean weight ranged from 14 to 36.8 kg. Ozen et al. Sandeman et al., and Wang et al. used ultrasound (US) to perform DPNB. In the remaining studies DPNB was performed using landmarks [ , , , , ]. The baseline characteristics were most commonly comparable between groups, as shown in Table 1 .
| N. | Study | Country | Study | Sample size, DPNB/CB | Age, years a DPNB/CB | Weight, kg a DPNB/CB | Duration of surgery, min a DPNB/CB | General anesthesia | Guide for DPNB | Local anesthetic CB | Local anesthetic DPNB | Rescue analgesic |
|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Design | ||||||||||||
| 1 | Bengisun 2012 [ ] | Turkey | RCT | 30/30 | 7/6 | 26/23 | 33/26 | Propofol 2–3 mg/kg | Landmark | Levobupivacaine 0.25 %, 1 mg/kg | Levobupivacaine 0.25 %, 1 mg/kg | Paracetamol 15 mg/kg every 4 h if required |
| 2 | Beyaz 2011 [ ] | Turkey | RCT | 23/24 | 8.5/7.4 | 29.4/23.4 | NA | Propofol 2–3 mg/kg | Landmark | Levobupivacaine 0.25 %, 0.5 mg/kg | Levobupivacaine 0.25 %, 0.5 mg/kg | 1 mg/kg of IV tramadol |
| 3 | Haliloglu 2013 [ ] | Turkey | RCT | 46/58 | 3.58/3.84 | NA | 22.7/22.5 | NA | Landmark | Bupivacaine 0.25 %, 0.2 mg/kg | Bupivacaine 0.25 %, 0.2 mg/kg | NA |
| 4 | Karatas 2021 [ ] | Turkey | RCT | 20/20 | 5.93/6.7 | 24.5/24.4 | 29.7/28.4 | Thiopental 5–7 mg/kg or 8 % sevoflurane with 70 % N2O in oxygen | Landmark | Bupivacaine 0.25 %, | Bupivacaine 0.25 %, 0.3 ml/kg | 1 mg/kg meperidine hydrochloride IV |
| 1 ml/kg | ||||||||||||
| 5 | Mak 2001 [ ] | China | RCT | 63/61 | 6.5/6.5 | 23.3/24.6 | NA | Sevoflurane or propofol | Landmark | Bupivacaine 0.25 %, 0.5 ml/kg | Bupivacaine 0.5 % | Oral paracetamol syrup in age-adjusted dosage |
| 6 | Munevveroglu 2020 [ ] | Turkey | Obs. | 100/100 | 4.8/4.5 | 17.8/18.5 | 13/13 | Propofol 2–3 mg/kg and fentanyl 2 μg/kg. | Landmark | Bupivacaine 0.25 %, 0.2 ml/kg | Bupivacaine 0.25 %, 0.2 ml/kg | NA |
| 7 | Ozen 2020 [ ] | Turkey | Obs. | 70/70 | 7/6 | 28/23 | 20/19 | Propofol 2–3 mg/kg and fentanyl 0.5 μg/kg | Ultrasound | Bupivacaine 0.25 %, 0.2 ml/kg | Bupivacaine 0.25 %, 0.2 ml/kg | Ibuprofen 10 mg/kg |
| 8 | Sandeman 2010 b [ ] | Australia | Obs. | 46/55/115 | 5/5/3 | 23/21/14 | 50/51/49 | NA | Landmark and Ultrasound | Ropivacaine 0.2 %, 1 ml/kg | Ropivacaine 0.2 % | Morphine |
| 9 | El Sersi 2023 [ ] | Egypt | RCT | 27/27 | 4.59/3.98 | 16.37/16.22 | NA | Sevoflurane | Landmark | Bupivacaine 0.25 %, 0.5 ml/kg | Bupivacaine 0.25 % | Paracetamol |
| 20 mg/kg | ||||||||||||
| 10 | Vater 1985 [ ] | United Kingdom | RCT | 25/25 | 4.6/5.6 | 18.1/20.3 | 29.3/30.3 | NA | Landmark | Bupivacaine 0.25 %, 0.5 ml/kg | Bupivacaine 0.5 % | Morphine |
| 0.15 mg/kg | ||||||||||||
| 11 | Wang 2019 [ ] | China | RCT | 52/52 | 11/12.5 | 32.5/36.8 | 28.9/28.3 | Sevoflurane | Ultrasound | Ropivacaine 0.25 %, 0.5 ml/kg | Ropivacaine 0.25 % | NA |
| 12 | Weksler 2005 [ ] | Israel | RCT | 50/50 | 5/5 | 20/20 | NA | Halothane in an admixture of nitrous oxide:oxygen (2:4 l/min). | Landmark | Bupivacaine 0.25 %, 1 ml/kg | Bupivacaine 0.5 %, 0.2 ml/kg | Oral paracetamol 15 mg/kg |
| 13 | Yeoman 1983 [ ] | United Kingdom | Obs. | 19/19 | 6.5/6,25 | 23.2/22.3 | NA | Thiopentone | Landmark | Bupivacaine 0.5 %, | Bupivacaine 0.5 % | Diamorphine 0.1 mg/kg IM. |
| 4.5 mg/kg | ||||||||||||
| 14 | Çomez 2022 [ ] | Turkey | RCT | 74/74 | NA | NA | NA | Ketamine 2 mg/kg | Landmark | Levobupivacaine 0.25 %, 0.5 ml/kg | Levobupivacaine 0.25 %, 0.15 ml/kg | Paracetamol 15 mg/kg IV |
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