Is it appropriate to do this surgery under just regional anesthesia? What form of regional anesthesia would you choose? Would your choice be different if the patient was 1-year-old? Does the block need to be performed while the patient is awake in either case? What agents would you choose to use for this block?

On awakening the patient has bilateral foot drop. He is otherwise neurologically intact. What are the possible causes and what is your management?

Depending on the exact length of the case, it would be possible to perform this surgery under spinal or epidural anesthesia alone. On the other hand, it is exceedingly rare that a 13-year-old would want to lay supine for 3–5 h while a case like this is performed – so this is really not a viable option. Psychologically, operations of the perineum are difficult to perform on an awake adolescent. The choice would be to accomplish the case with regional anesthesia plus monitored anesthesia care/deep sedation or provide a general anesthetic in addition to the chosen block. Either method would be acceptable; I would choose general anesthesia with the regional block. A dorsal penile nerve block could be performed by directing a block needle perpendicularly at the level of the symphysis pubis and inserting local anesthesia just under Scarpa’s fascia approximately 1.5 cm lateral to midline bilaterally. This could be done with ultrasound guidance or by landmarks alone. This block does not provide as complete nerve blockade (in general) as an epidural or spinal block. For a case of this duration, I would choose to simply provide GA with an LMA in addition to the nerve blockade. I would choose epidural anesthesia to allow for the duration of the surgery and to provide the option of using the block for postoperative pain control. If the child were only 1-year-old, I would choose a caudal block with a catheter insertion. There is excellent data to support the safety of “asleep” nerve blocks in pediatric age patients. While it is helpful to be able to receive feedback on paresthesias, etc. during the block placement, several large observational studies of central and peripheral nerve blocks in pediatric age patients have not shown a significant incidence of injury from blocks performed while patients are anesthetized. I would place an epidural catheter at L4–5, and I would choose 0.25 % bupivacaine or ropivacaine – 0.2 % for this block. To maintain the block, an infusion of bupivacaine could be continued at 0.4 mg/kg during the case.