Intraoperative nerve blocks for pain reduction in robotic peritoneal flap vaginoplasty: A prospective cohort study

BACKGROUND: Achieving adequate analgesia in patients undergoing vaginoplasty facilitates early ambulation, reduces postoperative morbidity and increases patient satisfaction. This study evaluated the use of intraoperative nerve blocks (transverse abdominis plane [TAP] block and perineal block) in reducing postoperative pain and decreasing opioid use in robotic-assisted peritoneal flap vaginoplasty. METHODS: A prospective cohort study of 150 consecutive adult patients undergoing robotic peritoneal flap vaginoplasty performed by the senior authors was conducted at a single institution from December 2023 to October 2024. 75 consecutive patients who did not receive a block and 75 consecutive patients who did receive blocks were included based upon power analysis calculations with assumptions yielding 99% power. Demographic data as well as multimodal analgesic use was compared between groups with respect to use during the preoperative, intraoperative, and post anesthesia phases of care, as well as on each day of inpatient admission. RESULTS: Groups did not differ significantly in baseline characteristics. Block-treated patients demonstrated a significantly reduced total opioid requirement throughout their hospital stay, inclusive of intraoperative and perioperative dosing, as measured in total morphine milligram equivalents (MME) (median 675 versus 26 MME; p < 0.001). Block-treated patients required almost no oxycodone or hydromorphone after surgery with a median oxycodone dose of 0 mg compared with 33 mg in controls (p < 0.001); their total median hydromorphone dose was 0.4 mg versus 1.2 mg (p < 0.001). CONCLUSIONS: The block intervention achieved a dramatic reduction in total postoperative opioid use (oral and intravenous) throughout the hospital stay.