Paracervical block for laparoscopic supracervical hysterectomy yields mixed results

SCOTTSDALE, ARIZ. – Applying a paracervical block before laparoscopic supracervical hysterectomy improves some operative outcomes but not others, Dr. Rachel L. Barr said at the annual scientific meeting of the Society of Gynecologic Surgeons.

The 132 women undergoing scheduled ambulatory surgery for presumed benign indications were randomized evenly to receive paracervical injection of bupivacaine plus epinephrine or paracervical injection of normal saline as a placebo control, each in addition to standard anesthesia.

Overall, about one-third of women were admitted to the hospital after the surgery – the trial’s primary outcome – with no significant difference between groups, reported lead investigator Dr. Rachel L. Barr, an obstetrician-gynecologist at Mount Sinai Hospital in New York. The findings were similar when restricted to women admitted specifically for pain management.

The paracervical-block group consumed about one-tenth of a tablet less of narcotics per day after surgery. They also had significantly lower estimated blood loss, although the median value was identical at 100 mL.

"The paracervical block with bupivacaine and epinephrine before laparoscopic supracervical hysterectomy is recommended to decrease the number of postoperative narcotic tablets consumed. It has the additional benefit of decreased blood loss and was found to be safe," Dr. Barr commented. "However, it was not effective at decreasing admissions for pain control."

"My first question for the authors relates to the clinical vs. statistical significance of the estimated blood loss and its variability in measurement and whether the authors considered using hematocrit in the study design," said invited discussant Dr. Clifford Wai of the division of female pelvic medicine and reconstructive surgery, University of Texas Southwestern Medical Center, Dallas.

The attending surgeon who performed all of the hysterectomies was very experienced, which likely helped achieve fairly low estimated blood loss in general, according to Dr. Barr. "So within this population, maybe the 50-mL difference between the two groups [in interquartile ranges] may not be that clinically significant."

"However, if you were to generalize this to other surgeons who maybe don’t do quite as many laparoscopic supracervical hysterectomies or on average have a higher blood loss, there may be a role for the paracervical block in helping decrease their blood loss, and you may see a larger decrease in blood loss when using the block," she added. "In addition, I think the block can be used as a tool to reduce blood loss in cases where, based on uterine size or pathology, you might predict there would be a higher blood loss, or in patients who have a lower hematocrit to begin with and refuse transfusions; this might decrease their blood loss and improve their recovery."

The investigators did not use hematocrit because they expected many patients to go home after surgery, and they do not routinely obtain a complete blood cell count in the postanesthesia care unit unless there is a clinical indication, she said at the meeting jointly sponsored by the American College of Surgeons.

"My second question is, given the limitations of the study, do the authors feel the conclusions justify a change in clinical practice?" Dr. Wai asked.

"We do now use the paracervical block with bupivacaine and epinephrine for all of our patients prior to laparoscopic supracervical hysterectomy," Dr. Barr replied.

Session attendee Dr. William W. Hurd, professor of obstetrics and gynecology at Duke University, Durham, N.C., and director of the division of reproductive endocrinology and infertility at the Duke Fertility Center, wondered, "Do you think that tiny change in pain medication would be clinically significant?"

"I do," Dr. Barr answered. "Maybe it’s not clinically significant just looking at that one value. But when you are talking to your patients preoperatively and they are asking, ‘Doctor, am I going to be taking tons of narcotics after? Am I going to get addicted?’ I think you can reassure them that over their postoperative course they might only need to take one or two tablets instead of two or three over several days. This might not seem like a lot to us, but I think that difference is reassuring to our patients."

The investigators studied patients undergoing laparoscopic supracervical hysterectomy at Mount Sinai Hospital between 2011 and 2013.

"In designing our study, we had noted that many patients at our institution were staying overnight electively in the hospital for pain management despite otherwise being stable for discharge home following laparoscopic hysterectomy," noted Dr. Barr.

The paracervical injection was performed after intubation but before the uterine manipulator was inserted or the abdominal incision was made. Admission was defined as at least one overnight stay in the hospital.

Results showed that the paracervical block and control groups were statistically indistinguishable with respect to the overall admission rate (41% vs. 28%) and the unplanned admission rate (34% vs. 27%). In the subset with an unplanned admission, 21 women were admitted for pain management: 10 in the paracervical-block group and 11 in the control group.

Use of fentanyl and use of oxycodone while in the postanesthesia care unit did not differ significantly between groups. However, in the first 14 days after surgery, the paracervical block group consumed fewer tablets of narcotics per day (0.58 vs. 0.71) and more tablets of over-the-counter analgesics per day (1.02 vs. 0.77). Mean pain scores during the first 2 postoperative days were essentially the same.

"Maybe the patients who didn’t have the block were using narcotics more to achieve a lower pain score. That’s one way to think about it," Dr. Barr proposed.

The two groups had similar rates of perioperative outcomes such as operative time and complications. Estimated median blood loss was generally low, but significantly lower in the paracervical block group.

"Out of all 132 patients, we only had 7 patients who had a blood loss greater than or equal to 500 mL, and the largest blood loss was 900 mL. Also, there were no transfusions," she pointed out.

Three patients – two in the paracervical block group and one in the control group – developed a cervical infection after surgery. All were successfully treated with oral antibiotics.

"The hysterectomies were all supracervical so the results may not apply to total hysterectomies, and we did not control for additional procedures performed at the same time," Dr. Barr noted.

Dr. Barr disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Applying a paracervical block before laparoscopic supracervical hysterectomy improves some operative outcomes but not others, Dr. Rachel L. Barr said at the annual scientific meeting of the Society of Gynecologic Surgeons.

The 132 women undergoing scheduled ambulatory surgery for presumed benign indications were randomized evenly to receive paracervical injection of bupivacaine plus epinephrine or paracervical injection of normal saline as a placebo control, each in addition to standard anesthesia.

Overall, about one-third of women were admitted to the hospital after the surgery – the trial’s primary outcome – with no significant difference between groups, reported lead investigator Dr. Rachel L. Barr, an obstetrician-gynecologist at Mount Sinai Hospital in New York. The findings were similar when restricted to women admitted specifically for pain management.

The paracervical-block group consumed about one-tenth of a tablet less of narcotics per day after surgery. They also had significantly lower estimated blood loss, although the median value was identical at 100 mL.

"The paracervical block with bupivacaine and epinephrine before laparoscopic supracervical hysterectomy is recommended to decrease the number of postoperative narcotic tablets consumed. It has the additional benefit of decreased blood loss and was found to be safe," Dr. Barr commented. "However, it was not effective at decreasing admissions for pain control."

"My first question for the authors relates to the clinical vs. statistical significance of the estimated blood loss and its variability in measurement and whether the authors considered using hematocrit in the study design," said invited discussant Dr. Clifford Wai of the division of female pelvic medicine and reconstructive surgery, University of Texas Southwestern Medical Center, Dallas.

The attending surgeon who performed all of the hysterectomies was very experienced, which likely helped achieve fairly low estimated blood loss in general, according to Dr. Barr. "So within this population, maybe the 50-mL difference between the two groups [in interquartile ranges] may not be that clinically significant."

"However, if you were to generalize this to other surgeons who maybe don’t do quite as many laparoscopic supracervical hysterectomies or on average have a higher blood loss, there may be a role for the paracervical block in helping decrease their blood loss, and you may see a larger decrease in blood loss when using the block," she added. "In addition, I think the block can be used as a tool to reduce blood loss in cases where, based on uterine size or pathology, you might predict there would be a higher blood loss, or in patients who have a lower hematocrit to begin with and refuse transfusions; this might decrease their blood loss and improve their recovery."

The investigators did not use hematocrit because they expected many patients to go home after surgery, and they do not routinely obtain a complete blood cell count in the postanesthesia care unit unless there is a clinical indication, she said at the meeting jointly sponsored by the American College of Surgeons.

"My second question is, given the limitations of the study, do the authors feel the conclusions justify a change in clinical practice?" Dr. Wai asked.

"We do now use the paracervical block with bupivacaine and epinephrine for all of our patients prior to laparoscopic supracervical hysterectomy," Dr. Barr replied.

Session attendee Dr. William W. Hurd, professor of obstetrics and gynecology at Duke University, Durham, N.C., and director of the division of reproductive endocrinology and infertility at the Duke Fertility Center, wondered, "Do you think that tiny change in pain medication would be clinically significant?"

"I do," Dr. Barr answered. "Maybe it’s not clinically significant just looking at that one value. But when you are talking to your patients preoperatively and they are asking, ‘Doctor, am I going to be taking tons of narcotics after? Am I going to get addicted?’ I think you can reassure them that over their postoperative course they might only need to take one or two tablets instead of two or three over several days. This might not seem like a lot to us, but I think that difference is reassuring to our patients."

The investigators studied patients undergoing laparoscopic supracervical hysterectomy at Mount Sinai Hospital between 2011 and 2013.

"In designing our study, we had noted that many patients at our institution were staying overnight electively in the hospital for pain management despite otherwise being stable for discharge home following laparoscopic hysterectomy," noted Dr. Barr.

The paracervical injection was performed after intubation but before the uterine manipulator was inserted or the abdominal incision was made. Admission was defined as at least one overnight stay in the hospital.

Results showed that the paracervical block and control groups were statistically indistinguishable with respect to the overall admission rate (41% vs. 28%) and the unplanned admission rate (34% vs. 27%). In the subset with an unplanned admission, 21 women were admitted for pain management: 10 in the paracervical-block group and 11 in the control group.

Use of fentanyl and use of oxycodone while in the postanesthesia care unit did not differ significantly between groups. However, in the first 14 days after surgery, the paracervical block group consumed fewer tablets of narcotics per day (0.58 vs. 0.71) and more tablets of over-the-counter analgesics per day (1.02 vs. 0.77). Mean pain scores during the first 2 postoperative days were essentially the same.

"Maybe the patients who didn’t have the block were using narcotics more to achieve a lower pain score. That’s one way to think about it," Dr. Barr proposed.

The two groups had similar rates of perioperative outcomes such as operative time and complications. Estimated median blood loss was generally low, but significantly lower in the paracervical block group.

"Out of all 132 patients, we only had 7 patients who had a blood loss greater than or equal to 500 mL, and the largest blood loss was 900 mL. Also, there were no transfusions," she pointed out.

Three patients – two in the paracervical block group and one in the control group – developed a cervical infection after surgery. All were successfully treated with oral antibiotics.

"The hysterectomies were all supracervical so the results may not apply to total hysterectomies, and we did not control for additional procedures performed at the same time," Dr. Barr noted.

Dr. Barr disclosed no relevant conflicts of interest.

SCOTTSDALE, ARIZ. – Applying a paracervical block before laparoscopic supracervical hysterectomy improves some operative outcomes but not others, Dr. Rachel L. Barr said at the annual scientific meeting of the Society of Gynecologic Surgeons.

The 132 women undergoing scheduled ambulatory surgery for presumed benign indications were randomized evenly to receive paracervical injection of bupivacaine plus epinephrine or paracervical injection of normal saline as a placebo control, each in addition to standard anesthesia.

Overall, about one-third of women were admitted to the hospital after the surgery – the trial’s primary outcome – with no significant difference between groups, reported lead investigator Dr. Rachel L. Barr, an obstetrician-gynecologist at Mount Sinai Hospital in New York. The findings were similar when restricted to women admitted specifically for pain management.

The paracervical-block group consumed about one-tenth of a tablet less of narcotics per day after surgery. They also had significantly lower estimated blood loss, although the median value was identical at 100 mL.

"The paracervical block with bupivacaine and epinephrine before laparoscopic supracervical hysterectomy is recommended to decrease the number of postoperative narcotic tablets consumed. It has the additional benefit of decreased blood loss and was found to be safe," Dr. Barr commented. "However, it was not effective at decreasing admissions for pain control."

"My first question for the authors relates to the clinical vs. statistical significance of the estimated blood loss and its variability in measurement and whether the authors considered using hematocrit in the study design," said invited discussant Dr. Clifford Wai of the division of female pelvic medicine and reconstructive surgery, University of Texas Southwestern Medical Center, Dallas.

The attending surgeon who performed all of the hysterectomies was very experienced, which likely helped achieve fairly low estimated blood loss in general, according to Dr. Barr. "So within this population, maybe the 50-mL difference between the two groups [in interquartile ranges] may not be that clinically significant."

"However, if you were to generalize this to other surgeons who maybe don’t do quite as many laparoscopic supracervical hysterectomies or on average have a higher blood loss, there may be a role for the paracervical block in helping decrease their blood loss, and you may see a larger decrease in blood loss when using the block," she added. "In addition, I think the block can be used as a tool to reduce blood loss in cases where, based on uterine size or pathology, you might predict there would be a higher blood loss, or in patients who have a lower hematocrit to begin with and refuse transfusions; this might decrease their blood loss and improve their recovery."

The investigators did not use hematocrit because they expected many patients to go home after surgery, and they do not routinely obtain a complete blood cell count in the postanesthesia care unit unless there is a clinical indication, she said at the meeting jointly sponsored by the American College of Surgeons.

"My second question is, given the limitations of the study, do the authors feel the conclusions justify a change in clinical practice?" Dr. Wai asked.

"We do now use the paracervical block with bupivacaine and epinephrine for all of our patients prior to laparoscopic supracervical hysterectomy," Dr. Barr replied.

Session attendee Dr. William W. Hurd, professor of obstetrics and gynecology at Duke University, Durham, N.C., and director of the division of reproductive endocrinology and infertility at the Duke Fertility Center, wondered, "Do you think that tiny change in pain medication would be clinically significant?"

"I do," Dr. Barr answered. "Maybe it’s not clinically significant just looking at that one value. But when you are talking to your patients preoperatively and they are asking, ‘Doctor, am I going to be taking tons of narcotics after? Am I going to get addicted?’ I think you can reassure them that over their postoperative course they might only need to take one or two tablets instead of two or three over several days. This might not seem like a lot to us, but I think that difference is reassuring to our patients."

The investigators studied patients undergoing laparoscopic supracervical hysterectomy at Mount Sinai Hospital between 2011 and 2013.

"In designing our study, we had noted that many patients at our institution were staying overnight electively in the hospital for pain management despite otherwise being stable for discharge home following laparoscopic hysterectomy," noted Dr. Barr.

The paracervical injection was performed after intubation but before the uterine manipulator was inserted or the abdominal incision was made. Admission was defined as at least one overnight stay in the hospital.

Results showed that the paracervical block and control groups were statistically indistinguishable with respect to the overall admission rate (41% vs. 28%) and the unplanned admission rate (34% vs. 27%). In the subset with an unplanned admission, 21 women were admitted for pain management: 10 in the paracervical-block group and 11 in the control group.

Use of fentanyl and use of oxycodone while in the postanesthesia care unit did not differ significantly between groups. However, in the first 14 days after surgery, the paracervical block group consumed fewer tablets of narcotics per day (0.58 vs. 0.71) and more tablets of over-the-counter analgesics per day (1.02 vs. 0.77). Mean pain scores during the first 2 postoperative days were essentially the same.

"Maybe the patients who didn’t have the block were using narcotics more to achieve a lower pain score. That’s one way to think about it," Dr. Barr proposed.

The two groups had similar rates of perioperative outcomes such as operative time and complications. Estimated median blood loss was generally low, but significantly lower in the paracervical block group.

"Out of all 132 patients, we only had 7 patients who had a blood loss greater than or equal to 500 mL, and the largest blood loss was 900 mL. Also, there were no transfusions," she pointed out.

Three patients – two in the paracervical block group and one in the control group – developed a cervical infection after surgery. All were successfully treated with oral antibiotics.

"The hysterectomies were all supracervical so the results may not apply to total hysterectomies, and we did not control for additional procedures performed at the same time," Dr. Barr noted.

Dr. Barr disclosed no relevant conflicts of interest.