K. Malik3, R. S. Chamberlain1,2,3 1Saint Barnabas Medical Center,Surgery,Livingston, NJ, USA 2New Jersey Medical School,Surgery,Newark, NJ, USA 3St. George’s University School Of Medicine,St. George’s, St. George’s, Grenada
PURPOSE: Circumcision is one of the most common surgeries performed in the pediatric population. Multiple local analgesia techniques including caudal block (CB) and penile block (PB) have been utilized and championed as offering optimal pain control during circumcision in toddlers and older children with no clear consensus. This meta-analysis investigates the efficacy of CB and PB during circumcision and their impact on postoperative analgesic requirements in the pediatric population age 16 months to 18 years.
Methods: A comprehensive literature search of PubMed, Google Scholar, and Cochrane Central Registry of Controlled Trials (1966-2015) was completed for all published randomized control trials (RCTs). Keywords searched included ‘circumcision’, ‘caudal block’, and ‘penile block’. Inclusion criteria were limited to the comparison of PB versus CB in children 16 months to 18 years of age and its efficacy towards circumcision. The efficacy, time to first additive analgesia, time to first micturition, duration of prolonged motor blockade, incidence of vomiting, and length of stay were analyzed.
Results: 9 RCTs involving 574 children, 287 undergoing PB and 287 undergoing CB, were included. There was no difference between the efficacy (relative risk (RR) = 0.983, 95% confidence interval (CI) = 0.95 to 1.02; p = 0.328) or time to first additive analgesia (standardized difference in mean (SDM) = 0.510, CI = -0.07 to 1.09; p = 0.066). Time to first micturition (SDM = 0.767, CI = 0.51 to 1.02; p < 0.001) and duration of motor blockade (SDM = 0.788, CI = 0.08 to 1.50, and p = 0.03) was significantly greater for CB. No differences were observed between CB and PB for the incidence of vomiting (RR = 1.56, CI = 0.91 to 2.67, and p = 0.11) and length of stay (SDM = 0.741, CI = -0.05 to 1.53 and p = 0.066). No differences between levobupivacaine and bupivacaine are observed in regards to the efficacy of the blocks (p = 0.570), time to first micturition (p = 0.196), duration of prolonged motor blockade (p = 0.098), and risk of vomiting (p = 0.825).
Conclusion: CB and PB offer equivalent anesthetic outcomes in pediatric patients’ age 16 months to 18 years undergoing circumcision. CB is associated with a longer time to urination and ambulation. Additional adequately powered studies are needed to further investigate optimal medication dose and anesthetic choice.
