Comparison of sacral erector spinae plane block and caudal epidural block for postoperative analgesia in pediatric hypospadias surgery: a prospective observational study

BACKGROUND: Effective postoperative analgesia is essential in pediatric urogenital surgery to reduce stress responses and opioid exposure. Caudal epidural block is widely used for hypospadias repair; however, its duration may be limited and it is associated with neuraxial-related concerns. Sacral erector spinae plane (ESP) block has recently emerged as a potential alternative regional technique. This study aimed to compare the analgesic efficacy of sacral ESP block and caudal epidural block in children undergoing hypospadias surgery. METHODS: of 0.25% bupivacaine. Postoperative pain was assessed using the Face, Legs, Activity, Cry, Consolability (FLACC) scale at 1, 2, 4, 6, 12, and 24 h postoperatively by a blinded observer. The primary outcome was FLACC score at postoperative 12 h. Secondary outcomes included pain scores at other time points, time to first rescue analgesic, postoperative analgesic consumption, and block-related complications. RESULTS: Eighty-six patients were analyzed (43 per group), with no significant differences in baseline characteristics. Median FLACC scores were significantly lower in the sacral ESP group at all postoperative time points, including the primary endpoint at 12 h (0 [0-0] vs. 1 [0-2], p < 0.001). Time to first rescue analgesic was significantly longer in the sacral ESP group (mean 22.7 h, 95% CI 21.5-23.9) compared with the caudal group (13.7 h, 95% CI 10.9-16.6; p < 0.001). The median number of postoperative analgesic administrations was lower in the sacral ESP group (0 [0-0] vs. 1 [0-1], p < 0.001). No block-related complications were observed in either group. CONCLUSIONS: Ultrasound-guided sacral erector spinae plane block was associated with lower postoperative pain scores, prolonged time to rescue analgesia, and reduced analgesic consumption compared with caudal epidural block in pediatric patients undergoing hypospadias surgery. Sacral ESP block may represent a useful alternative to caudal epidural block; however, randomized controlled studies are required to confirm these findings. TRIAL REGISTRATION: ClinicalTrials.gov, NCT07286786.