A Novel Injection Technique for Extended-Release Local Anesthetic After Posterior Colporrhaphy and Perineorrhaphy: A Randomized Controlled Study

Abstract

Objectives To evaluate the effect of vaginal intraoperative infiltration of liposomal bupivacaine on vaginal pain among patients undergoing posterior colporrhaphy and perineorrhaphy. Methods This was a randomized, placebo-controlled trial offered to women undergoing posterior colporrhaphy and perineorrhaphy with concomitant pelvic reconstructive procedures. Liposomal bupivacaine or normal saline placebo (30 mL) was injected into the posterior vaginal compartment and perineal body in 2- to 3-mL increments, using a systematic technique. All participants received 10-mL 0.25% bupivacaine with epinephrine prior to incision. Perioperative care was standardized. The primary outcome was vaginal pain as measured by a visual analog scale. Results One hundred twenty-six women were screened, and 72 were included. Demographic characteristics were similar. Median visual analog scale was not different at any time point (P = 0.81). There were no differences in secondary outcomes, including narcotic use (37.5 vs 37.5 mg morphine equivalents, P = 0.51; placebo vs liposomal bupivacaine), time to first opioid (68 vs 89.5 minutes, P = 0.56), antiemetic doses (3 vs 2, P = 0.07), hospital length of stay (24 vs 21.9 hours, P = 0.98), length of stay in postanesthesia care unit (93 vs 100 minutes, P = 0.32), proportion of patients who had a bowel movement within the first 3 postoperative days (65.7 vs 59.5% P = 0.36), or successful voiding trials (45.7 vs 59.5%, P = 0.24). There were no differences in patient satisfaction or postoperative adverse events. Conclusions In this study of pelvic reconstructive surgeries with posterior colporrhaphy and perineorrhaphy, there were no differences in pain scores or any secondary outcomes between liposomal bupivacaine and placebo injected into the posterior vaginal compartment.

The effect of liposomal bupivacaine for surgical wound infiltration: A meta‐analysis of randomised controlled trials

“…During the full‐text screening process, 52 citations were excluded for the following reasons: irrelevant comparator or intervention (n = 7), did not report wound infiltration (n = 24), not being an RCT (n = 18), lack of available data (n = 2), or being an animal study (n = 1). Twenty‐two studies were included in this meta‐analysis 15‐18,28‐45 . A flow diagram of the study selection process is shown in Figure 1.…”

“…Of the studies that qualified for inclusion, surgeries were performed under general anaesthesia in 12 studies 16,18,28‐34,37,43,45 and under local anaesthesia in 10 15,17,35,36,38‐42,44 . The time of wound infiltration was the period before skin incision in three studies, 34,38,42 and the period before skin closure in 19 studies 15‐18,28‐33,35‐37,39‐41,43‐45 . For the surgical method, five studies with patients undergoing minimally invasive surgery, 34,36,40,42,45 15 studies with patients undergoing open surgery 15,16,18,28‐33,35,37‐39,43,44 .…”

“…The time of wound infiltration was the period before skin incision in three studies, 34,38,42 and the period before skin closure in 19 studies 15‐18,28‐33,35‐37,39‐41,43‐45 . For the surgical method, five studies with patients undergoing minimally invasive surgery, 34,36,40,42,45 15 studies with patients undergoing open surgery 15,16,18,28‐33,35,37‐39,43,44 . It should be pointed out that 2 studies 17,41 had patients undergoing both open and minimally invasive surgery, so we decided to exclude those two studies from the surgical method subgroup analysis 5 .…”

“…Finally, despite early data indicating that LB wound infiltration reduced pain intensity scores and postoperative opioid consumption, 2 subsequent RCTs have questioned the putative analgesic advantages of LB. To date, more trials have been conducted on the efficacy of LB for wound infiltration 15‐18 . However, the inclusion of a variety of outcome measures, numerous comparators, and distinct research designs has created a complex evidence landscape.…”

Bupivacaine Use After Posterior Colporrhaphy to Reduce Postoperative Pain: A Multicenter, Double-Blinded, Placebo-Controlled, Randomized Clinical Trial

“…Injecting 20 mL of liposomal bupivacaine versus placebo into the lateral vaginal walls/levator muscle areas and perineal body immediately after posterior colporrhaphy, colpocleisis, sphincteroplasty, or perineorrhaphy, this study showed no reduction in postoperative pain. Finally, in a recent study by Evans et al, 13 a 30-mL mixture of 20 mL of liposomal bupivacaine and 10 mL of normal saline was injected into the posterior vaginal compartment and perineal body after posterior colporrhaphy and perineorrhaphy. No differences were found in postoperative pain, time to first bowel movement, passage of postoperative voiding trial and days to passed voiding trial, length of stay, or narcotic use.…”