Nerve Blocks

Regional nerve blocks are the single most opioid-sparing intervention available to the reconstructive urologist. They fit into two categories relevant to reconstructive, functional, and urogynecologic practice: fascial plane blocks (TAP, quadratus lumborum, erector spinae, rectus sheath) for abdominal-wall analgesia in open and robotic reconstruction, and targeted peripheral blocks (pudendal, dorsal penile, penile ring, ilioinguinal / iliohypogastric, spermatic cord, periurethral) for perineal, penile, scrotal, and office-based female procedures. This article covers the local-anesthetic pharmacology that underlies every block, injection best practices and the pain-minimization techniques that matter in awake cases, the specific blocks relevant to GU reconstructive practice, and the evidence on liposomal bupivacaine (Exparel) — which despite manufacturer claims shows only modest benefit over standard agents.

See also: Anesthesia, Analgesia, Nausea & Vomiting, ERAS, Pelvic Neuroanatomy.

---

Local Anesthetic Pharmacology

Amide Local Anesthetics (Routine Nerve-Block Agents)

Agent	Concentration	Onset	Duration (nerve block)	Max dose
Lidocaine	0.5–2%	Fast	1–2 h	4.5 mg/kg; 7 mg/kg with epinephrine
Bupivacaine	0.25–0.5%	Slower	4–8 h	~2–3 mg/kg
Ropivacaine	0.2–0.75%	Slower	4–8 h	~3 mg/kg; less cardiac toxicity than bupivacaine
Levobupivacaine	0.25–0.5%	Slower	4–8 h	~2 mg/kg; improved safety vs bupivacaine
Mepivacaine	1–2%	Fast	2–4 h	4.5 mg/kg

Amides are metabolized hepatically; true allergy is rare.^[4]

Ester Local Anesthetics (Less Common for Blocks)

Chloroprocaine, 2-chloroprocaine (day-case spinal), tetracaine, procaine. Metabolized by plasma cholinesterases; allergy more common than with amides.^[10]

Pharmacokinetic Principles^[9][10]

• Lipid solubility → intrinsic potency
• Protein binding → duration
• pKa → onset speed (lower pKa = faster onset)
• Mass of drug — not volume or concentration — primarily drives block onset, success, and duration for standard agents

Mixing Lidocaine with Long-Acting Agents

Common practice to achieve faster onset with longer duration:^[11]

• Mixtures produce onset in ~16 min vs 23–28 min for long-acting alone
• Duration is significantly shorter than long-acting agent alone
• Plasma concentrations of long-acting agent are lower but offset by significant lidocaine levels
• Safety benefit is unclear

Duration-Extending Adjuvants

Added to standard local anesthetics to prolong block:^[5]

• Epinephrine 1:200,000 — vasoconstriction; reduces systemic absorption; adds ~1–2 h
• Dexamethasone 2–4 mg — the most reliable adjuvant; adds 4–8 h
• Clonidine 1 μg/kg — α2 agonist; adds 2–4 h
• Dexmedetomidine 0.5–1 μg/kg — α2; comparable to dexamethasone; sedative risk

Standard agents + adjuvants extend duration to ~12–24 h. For analgesia beyond that window, continuous catheter techniques outperform single-shot strategies — including single-shot liposomal bupivacaine (see below).

Local Anesthetic Systemic Toxicity (LAST)

Presents with neurologic symptoms first (perioral numbness, metallic taste, tinnitus, agitation, seizures), then cardiovascular collapse (arrhythmia, cardiac arrest).^[4]

Treatment sequence:

1. Stop injection.
2. Call for help. ACLS if in arrest, with modifications — avoid vasopressin, calcium channel blockers, β-blockers, and local anesthetic antiarrhythmics.
3. 20% lipid emulsion therapy — bolus 1.5 mL/kg over 1 min, then infusion 0.25 mL/kg/min. Repeat bolus and increase infusion for persistent instability.
4. Airway support and benzodiazepine for seizure.
5. Prolonged CPR may be needed — LAST arrests have recovered after extended resuscitation with lipid emulsion.

Every block location should have lipid emulsion immediately available.

---

Injection Best Practices

Fundamental Safety Principles^[1][2][3]

• Use the lowest effective dose.
• Aspirate before each injection to avoid intravascular placement.
• Incremental, slow injection — bolus delivery is the #1 driver of intravascular toxicity and infiltration pain.
• Monitor continuously for early LAST signs.

Pain-Minimization Techniques (Office and Awake Cases)^[1][2][3]

These are the evidence-based techniques for awake patients — e.g., office urethral dilation, perineal block before flexible cystoscopy:

• Buffer with sodium bicarbonate — 1 mL of 8.4% bicarb per 10 mL of lidocaine. The single most effective pain-reduction technique.
• Warm the solution to ~40°C.
• Small-gauge needles (27–30 gauge).
• Slow infiltration rate — again, probably the single most effective maneuver.
• Inject through already-anesthetized tissue after the first puncture. The initial needle insertion is the most painful.
• Vibration or cold-air skin cooling at the injection site.
• Circumferential field block around a lesion rather than directly into it.

---

Fascial Plane Blocks for Abdominal and Pelvic Reconstruction

Transversus Abdominis Plane (TAP) Block

Anatomy: injects local anesthetic into the plane between the internal oblique and transversus abdominis muscles, blanketing T10–L1 branches.

Coverage: lower abdominal wall — skin, subcutaneous, and parietal peritoneum of the incision. Does not cover visceral pain.

Typical dose: 15–30 mL of 0.25% bupivacaine or 0.375% ropivacaine per side (bilateral for midline or bilateral incisions).

Reconstructive-urology use:

• Open urinary diversion (ileal conduit, continent reservoir) performed as reconstructive rather than oncologic indication
• Ureteral reconstruction (open ureteroureterostomy, Boari flap, ileal ureter) via lower-abdominal incision
• Bladder augmentation (enterocystoplasty)
• Open pyeloplasty with subcostal or flank-adjacent incision
• Posterior urethroplasty via combined abdominoperineal approach
• Cesarean section and urogynecologic laparotomy

Limitations: visceral pain not covered; effect may decline faster than surgeon-administered local infiltration in some studies.^[17]

Quadratus Lumborum (QL) Block

Anatomy: injects into the fascial plane around the QL muscle (posterior, lateral, or transmuscular approach). Reaches further cephalad and covers thoracolumbar somatic + visceral pain — broader than TAP.

Typical dose: 20–30 mL per side.

Reconstructive-urology use:

• Robotic reconstructive abdominal procedures (ureteral reimplant, pyeloplasty, bladder reconstruction, augmentation)
• Open reconstructive abdominal work when broader coverage is desired
• Flank-based reconstructive approaches (open pyeloplasty)

Erector Spinae Plane (ESP) Block

Anatomy: injects into the plane deep to the erector spinae muscle at T7–T9. Spreads cephalad-caudad through the paravertebral space.

Typical dose: 20 mL of 0.375% ropivacaine per side, bilateral at T7–T9.

Reconstructive-urology use:

• Superior to TAP in the prospective Micali 2024 comparison of urologic laparoscopic/robotic cases within an ERAS protocol.^[17]
• Robotic reconstructive abdominal work (ureteral reconstruction, pyeloplasty, augmentation, bladder reconstruction)
• Major open abdominopelvic reconstruction

Rectus Sheath Block

Anatomy: injects between the posterior rectus sheath and the rectus muscle, blocking T9–T11 anterior branches.

Typical dose: 10–20 mL per side.

Reconstructive-urology use:

• Midline lower-abdominal reconstructive incisions (augmentation, Mitrofanoff, Boari flap, ileal ureter)
• Umbilical and periumbilical port-site incisions after robotic reconstruction
• Preferred in some ERAS pathways for its favorable analgesia-to-safety balance.

Choice Among Fascial Blocks — Summary

Incision / approach	Preferred block
Lower-abdominal midline (augmentation, Mitrofanoff, Boari flap, ileal ureter)	TAP or rectus sheath, bilateral
Robotic ureteral / bladder / pyeloplasty reconstruction	QL or ESP (ESP superior in RCT)
Open abdomen with broad visceral coverage need	QL
Pfannenstiel incision (sling, simple prostatectomy, retropubic reconstructive work)	TAP or ilioinguinal / iliohypogastric
Perineal reconstructive surgery	Pudendal (see below)

---

Peripheral Blocks Specific to Urology

Pudendal Nerve Block

The pudendal nerve (S2–S4) supplies the urethra, bladder trigone, penis/clitoris, perineum, and pelvic floor — the urologic sensory nerve par excellence.^[5][6]

Approaches

• Transvaginal / transperineal at the ischial spine (traditional) — needle inserted ~1 cm medial and posterior to the ischial spine, through the sacrospinous ligament. 7–10 mL per side, bilateral.^[4][7]
• Ultrasound-guided at Alcock canal — hip-bone margin traced from greater sciatic notch → ischial spine → lesser sciatic notch; needle directed into Alcock canal. 3–5 mL per side is sufficient.^[8]
• Nerve-stimulator-guided — electrical confirmation of proximity.^[5][9]
• Fluoroscopy-guided transgluteal — used for chronic pudendal neuralgia diagnostic/therapeutic blocks.^[10]
• Dual-site infiltration — ischial spine + intra-Alcock canal combined for enhanced efficacy.^[11]

Reconstructive / Functional-Urology Indications

• Perineal urethroplasty — primary analgesic for the perineal component; combine with general or regional for the abdominal component of combined approaches.
• Catheter-related bladder discomfort (CRBD) after transurethral or cystoscopic reconstructive procedures — bilateral pudendal block significantly reduces CRBD intensity and duration for up to 12 h postoperatively.^[5]
• Rectourethral fistula repair (transperineal approach, with or without gracilis interposition).
• Artificial urinary sphincter implantation (perineal approach).
• Perineal urethrostomy.
• Vaginal surgery in urogynecology — colporrhaphy, sacrospinous fixation, sacrocolpopexy with vaginal component, vaginal hysterectomy for prolapse.^[9][18]
• Pelvic organ prolapse surgery (anterior / posterior repair).

Urogynecology — the Khalil RCT

Nerve-stimulator-guided pudendal block vs general anesthesia for anterior/posterior vaginal wall repair produced:^[9]

• Significantly lower pain scores
• Reduced analgesic consumption
• Shorter recovery (3.6 vs 12.2 days)
• Higher patient satisfaction (71% vs 28%)

For stage I–II prolapse, pudendal block is a viable alternative to GA.

Dorsal Penile Nerve Block

The paired dorsal nerves of the penis (branches of the pudendal nerve) run deep to Buck's fascia on either side of the midline dorsal vein and supply the dorsal and ventral penile skin.^[12]

Approaches

• Traditional two-puncture subpubic — needle into the two compartments of the subpubic space at the penile base; 0.1 mL/kg per compartment in pediatrics.^[13]
• Ultrasound-guided at Buck's fascia — precise targeting of dorsal penile nerves in the fascial compartment just deep to Buck fascia; reduced volume, higher success.^[12]
• Perineal approach under ultrasound — an alternative to caudal block in pediatric hypospadias and circumcision.^[15][16]

Indications

• Hypospadias repair (primary or revision)
• Adult / pediatric circumcision and revision
• Paraphimosis reduction
• Priapism management / corporal drainage
• Penile shaft procedures (STSG, scar revision)

Duration data: US-guided dorsal penile block provided 32 h of analgesia vs 21 h for pudendal block in pediatric hypospadias.^[16]

Penile Ring Block

A separate (and commonly used) technique distinct from the dorsal penile block.

Technique: circumferential subcutaneous infiltration around the base of the penile shaft, placing a ring of local anesthetic that blocks all the small cutaneous branches reaching the penile skin from both the dorsal penile nerves and the ventral perineal branches of the pudendal.^[14]

• Typical dose: 5–10 mL of 0.5% bupivacaine (plain, no epinephrine — end-organ vasculature) or 1% lidocaine for adults; 0.1 mL/kg for pediatrics.
• Use a small-gauge needle (25–27 G).
• Inject slowly with frequent aspiration — circumferential vascular plexus at the penile base.

Complementary to or substitute for the dorsal penile block:

• Some surgeons combine the two for comprehensive penile-skin coverage (adult circumcision, complex hypospadias revision).
• Ring block alone is often sufficient for simple circumcision and office-based procedures on penile skin.
• Easier and faster than the dorsal block in the awake office setting.

Safety — absolute rule: never use epinephrine or any vasoconstrictor in a penile block. The penis is end-organ tissue and vasoconstrictor-induced ischemia can cause tip necrosis.

Periurethral Block (Female)

A local infiltration block at the urethral meatus and periurethral tissues — not a true nerve block but an important and widely used technique in office female reconstructive / functional urology.

Technique:

• Patient supine or low-lithotomy in the office.
• Topical lidocaine jelly applied to the urethral meatus for 5–10 min (adjunct, not a substitute for infiltration).
• 1% lidocaine 5–10 mL injected into the periurethral tissues at the 4-, 8-, and 12-o'clock positions around the meatus using a 25–27 G needle.
• Aspirate before each injection.
• Allow 3–5 min for onset before beginning the procedure.

Indications in functional urology:

• Urethral bulking agent injection (Bulkamid, Macroplastique, Coaptite) for stress urinary incontinence — the primary office use.
• Office cystoscopy in women who do not tolerate topical anesthesia alone.
• Office urethral dilation or calibration.
• Botulinum toxin injection into the urethral sphincter or bladder (when transurethral).
• Periurethral cyst drainage / small periurethral procedures.

Practical note: the bulking injection itself (through the cystoscope working channel or a dedicated transurethral needle) delivers local anesthetic via the injection pathway but a separate periurethral infiltration block produces a meaningfully better patient experience and is standard practice in many offices.

Spermatic Cord Block

Local blockade at the spermatic cord — a workhorse for office and operating-room scrotal-content procedures.

Anatomy: the spermatic cord contains the genital branch of the genitofemoral nerve (anterior/lateral), the ilioinguinal nerve (anterior/medial), and sympathetic fibers. These mediate most scrotal and cord sensation.

Technique:

• Identify the cord at the external inguinal ring or over the pubic tubercle (most accessible point).
• Stabilize the cord between thumb and index finger.
• Inject 10–20 mL of 1% lidocaine, 0.25–0.5% bupivacaine, or a mixture around and into the cord:
  • Superficial subcutaneous infiltration
  • Deep infiltration around the cord structures
• Never add epinephrine (testicular vascular risk).
• Allow 5–10 min for onset.
• Supplement with local infiltration at the skin incision.

Reconstructive / functional-urology indications:

• Vasectomy (office or OR)
• Vasectomy reversal / vasovasostomy (as analgesic adjunct to general or sedation)
• Hydrocelectomy (adjunct to general or regional)
• Spermatocelectomy
• Varicocelectomy (microsurgical subinguinal — as analgesic adjunct)
• Microdissection testicular sperm extraction (microTESE) — as analgesic adjunct
• Scrotal content biopsy
• Chronic scrotal / testicular pain — diagnostic cord block helps localize pain to cord structures and predict response to microsurgical denervation of the spermatic cord

Diagnostic-block caveat: for chronic scrotal pain work-up, a cord block with local anesthetic is both diagnostic and therapeutic — relief predicts likely success with surgical cord denervation.

Ilioinguinal / Iliohypogastric Block

The ilioinguinal (L1) and iliohypogastric (T12–L1) nerves supply the lower abdominal wall, inguinal region, and upper scrotum / labia.

Technique: 5–10 mL of 0.25% bupivacaine injected just medial to the ASIS, between the external and internal oblique fascia; ultrasound-guided placement dramatically improves success.

Urologic use:

• Orchiopexy
• Hydrocelectomy
• Inguinal scrotal / spermatic cord surgery
• Adjunct for Pfannenstiel or inguinal incisions
• Vulvar surgery — combined with pudendal block for major vulvectomy.^[18]

Uterosacral / Cervical and Paracervical Blocks

Relevant in urogynecology and combined reconstructive pelvic surgery:

• Pre-emptive uterosacral / cervical block (PUCB) — ropivacaine + clonidine at 2, 4, 8, and 10 o'clock of the cervix for vaginal hysterectomy / prolapse repair; significant pain reduction at 1 and 24 h.^[19]
• Paracervical block — local anesthetic at 2–6 sites, 3–7 mm depth, alongside the vaginal portion of the cervix; interrupts visceral sensory fibers (T10–L1). Historically used for labor analgesia; less common now with epidural.^[6]

---

Liposomal Bupivacaine (Exparel) — the Evidence

Liposomal bupivacaine is bupivacaine encapsulated in multivesicular liposomes, marketed for up to 72 h of analgesia.^[3][5] It is 10–20× more expensive than standard bupivacaine. The clinical question — does it deliver — has been answered repeatedly.

Ilfeld 2021 Anesthesiology — the Definitive Review

Comprehensive review of all 76 RCTs of liposomal bupivacaine:^[1]

• 92% of trials (11 of 12) showed standard bupivacaine PERIPHERAL NERVE BLOCK provides superior analgesia to infiltrated liposomal bupivacaine.
• Only 11% of trials (4 of 36) of surgical-site infiltration showed a clinically relevant improvement with liposomal bupivacaine.
• High-risk-of-bias trials favored liposomal bupivacaine 84% of the time; low-risk trials only 14% — a risk-of-bias signal.

Hussain 2021 Meta-Analysis — Perineural

9 RCTs, 619 patients, perineural injection:^[2]

• Improvement in pain score: 1.0 cm·h on 0–10 scale at 24–72 h (clinically unimportant).
• Nonsignificant when industry-sponsored trials excluded (0.7 cm·h, P=0.100).
• No differences in opioid consumption, time to first analgesic, patient satisfaction, LOS, or functional recovery.
• High-quality evidence does not support perineural liposomal bupivacaine over standard bupivacaine.

Hussain 2024 Anesthesiology — Fascial Plane (TAP)

16 RCTs, 1,287 patients:^[4]

• No difference in AUC pain scores (SMD -0.21, P=0.058)
• No difference in day-2 or day-3 pain, opioid consumption, or hospital stay
• Results consistent whether or not plain bupivacaine was mixed with liposomal

Nguyen 2023 Meta-Analysis — Summary

27 trials, 2,122 patients:^[3]

• Rest pain reduction: 0.9 points at 24 h; 0.7 at 48–72 h (below MCID)
• No morphine-consumption difference at any time point

Selected Positive Signals

• Supraclavicular brachial plexus — Chan 2024 RCT showed reduced pain day 1 (AUC 0.6 vs 1.4) but difference resolved by day 2–4.^[7]
• Continuous catheter with standard bupivacaine generally outperforms single-shot liposomal bupivacaine for >24 h analgesia.^[6]

Practical Stance for GU Reconstruction

• Standard bupivacaine, ropivacaine, or levobupivacaine with dexamethasone adjuvant remains the default for most peripheral nerve blocks and fascial plane blocks.
• Liposomal bupivacaine's ~0.7–0.9 point pain-score reduction does not reduce opioid use and does not justify the substantial per-case cost premium in most urologic contexts.
• For procedures requiring analgesia beyond 24 h, continuous catheter techniques with standard local anesthetic generally outperform single-shot liposomal bupivacaine.
• Institutional decisions to stock liposomal bupivacaine are increasingly skeptical in light of the high-quality negative evidence.

---

Practical Block Selection by Reconstructive / Functional Operation

Operation	Primary block	Local anesthetic
Open reconstructive abdominal surgery (augmentation, Mitrofanoff, ileal ureter, Boari flap)	TAP or rectus sheath, bilateral	0.25% bupivacaine 20 mL/side
Robotic reconstructive abdominal surgery (ureteral reimplant, pyeloplasty, augmentation)	QL or ESP (ESP superior)	0.375% ropivacaine 20 mL/side
Pfannenstiel incision (autologous sling, simple prostatectomy, retropubic reconstruction)	TAP or ilioinguinal / iliohypogastric	0.25% bupivacaine 15 mL/side
Perineal urethroplasty (bulbar / posterior)	Pudendal bilateral + perineal local infiltration	0.25% bupivacaine 7–10 mL/side
Rectourethral fistula repair (transperineal ± gracilis)	Pudendal bilateral	0.25% bupivacaine 7–10 mL/side
Artificial urinary sphincter (perineal)	Pudendal ± ilioinguinal	0.25% bupivacaine 7–10 mL/side
Vaginal prolapse repair / colporrhaphy	Pudendal bilateral ± pre-emptive uterosacral/cervical block (PUCB)	0.25% bupivacaine 7–10 mL/side
Sacrospinous ligament fixation	Pudendal bilateral	0.25% bupivacaine 7–10 mL/side
Major vulvar reconstructive surgery	Ilioinguinal + pudendal bilateral	0.25% levobupivacaine (max 2 mg/kg)
Hypospadias repair / adult or pediatric circumcision	Dorsal penile (US-guided) ± ring block	0.25% bupivacaine 0.1 mL/kg, no epi
Penile prosthesis / Peyronie's plaque excision	Dorsal penile + ring block	0.5% bupivacaine, no epi
Vasectomy / vasectomy reversal	Spermatic cord block	1% lidocaine 10 mL per cord, no epi
Hydrocelectomy / spermatocelectomy	Spermatic cord + local infiltration	0.25% bupivacaine 10–15 mL per cord
Varicocelectomy (microsurgical subinguinal)	Spermatic cord + ilioinguinal adjunct	0.25% bupivacaine
MicroTESE	Spermatic cord	0.25% bupivacaine
Chronic orchialgia — diagnostic cord block	Spermatic cord (diagnostic)	1% lidocaine 10 mL
Microsurgical denervation of spermatic cord	Spermatic cord	0.25% bupivacaine
Orchiopexy / hernia-related scrotal procedures	Ilioinguinal / iliohypogastric	0.25% bupivacaine 5–10 mL/side
Office urethral bulking (Bulkamid, Macroplastique)	Periurethral block + topical lidocaine	1% lidocaine 5–10 mL periurethral
Office cystoscopy (female, poorly tolerant)	Periurethral block	1% lidocaine 5–10 mL periurethral
Office urethral dilation / calibration (female)	Periurethral block	1% lidocaine 5–10 mL periurethral
Office flexible cystoscopy (routine)	Topical lidocaine gel (intraurethral)	2% lidocaine jelly

---

Key Takeaways

1. Mass of drug, not volume or concentration, primarily drives block onset, success, and duration.
2. Aspirate, inject slowly, monitor continuously. Every block location should have lipid emulsion immediately available.
3. Buffer lidocaine with 1:10 sodium bicarb for awake injections — biggest single pain-reduction lever.
4. Dexamethasone adjuvant is the most reliable duration-extending additive.
5. For robotic abdominal reconstruction — ESP ≥ QL > TAP (Micali 2024 ERAS RCT data).
6. Pudendal block for perineal urethroplasty, RUF repair, AUS, and vaginal prolapse repair — a nerve-stimulator or US-guided pudendal block substantially reduces postoperative opioid use and, for prolapse repair, can serve as the primary anesthetic (Khalil RCT — 3.6 d recovery vs 12.2 d with GA).
7. US-guided dorsal penile block is the standard for hypospadias repair and adult circumcision; penile ring block is a complementary or alternative technique for broader cutaneous coverage. Never add epinephrine to a penile block (end-organ ischemia risk).
8. Spermatic cord block is a workhorse for vasectomy (office or OR), hydrocele / spermatocele, varicocelectomy, microTESE, and as a diagnostic block for chronic scrotal pain predicting response to microsurgical cord denervation.
9. Periurethral block is the office-technique companion to female reconstructive practice — standard for urethral bulking (Bulkamid, Macroplastique), office cystoscopy in poorly tolerant patients, and urethral dilation.
10. Liposomal bupivacaine is not worth the cost for most reconstructive blocks — standard bupivacaine ± dexamethasone or a continuous catheter outperforms it.
11. LAST treatment is lipid emulsion — 1.5 mL/kg bolus then 0.25 mL/kg/min, with prolonged CPR if needed.

---

References

1. Ilfeld BM, Eisenach JC, Gabriel RA. "Clinical Effectiveness of Liposomal Bupivacaine Administered by Infiltration or Peripheral Nerve Block to Treat Postoperative Pain." Anesthesiology. 2021;134(2):283–344. doi:10.1097/ALN.0000000000003630

2. Hussain N, Brull R, Sheehy B, et al. "Perineural Liposomal Bupivacaine Is Not Superior to Nonliposomal Bupivacaine for Peripheral Nerve Block Analgesia." Anesthesiology. 2021;134(2):147–164. doi:10.1097/ALN.0000000000003651

3. Nguyen A, Grape S, Gobbetti M, Albrecht E. "The Postoperative Analgesic Efficacy of Liposomal Bupivacaine Versus Long-Acting Local Anaesthetics for Peripheral Nerve and Field Blocks — A Systematic Review and Meta-Analysis." Eur J Anaesthesiol. 2023;40(9):624–635. doi:10.1097/EJA.0000000000001833

4. Hussain N, Speer J, Abdallah FW. "Analgesic Effectiveness of Liposomal Bupivacaine Versus Plain Local Anesthetics for Abdominal Fascial Plane Blocks — A Systematic Review and Meta-Analysis." Anesthesiology. 2024;140(5):906–919. doi:10.1097/ALN.0000000000004932

5. Xiaoqiang L, Xuerong Z, Juan L, et al. "Efficacy of Pudendal Nerve Block for Alleviation of Catheter-Related Bladder Discomfort in Male Patients Undergoing Lower Urinary Tract Surgeries — A Randomized, Controlled, Double-Blind Trial." Medicine. 2017;96(49):e8932. doi:10.1097/MD.0000000000008932

6. Jin Z, Ding O, Islam A, Li R, Lin J. "Comparison of Liposomal Bupivacaine and Conventional Local Anesthetic Agents in Regional Anesthesia — A Systematic Review." Anesth Analg. 2021;132(6):1626–1634. doi:10.1213/ANE.0000000000005406

7. Chan TCW, Wong JSH, Wang F, et al. "Addition of Liposomal Bupivacaine to Standard Bupivacaine Versus Standard Bupivacaine Alone in the Supraclavicular Brachial Plexus Block — A Randomized Controlled Trial." Anesthesiology. 2024;141(4):732–744. doi:10.1097/ALN.0000000000005035

8. Bendtsen TF, Parras T, Moriggl B, et al. "Ultrasound-Guided Pudendal Nerve Block at the Entrance of the Pudendal (Alcock) Canal — Description of Anatomy and Clinical Technique." Reg Anesth Pain Med. 2016;41(2):140–5. doi:10.1097/AAP.0000000000000355

9. Khalil I, Itani SE, Naja Z, et al. "Nerve Stimulator-Guided Pudendal Nerve Block vs General Anesthesia for Postoperative Pain Management After Anterior and Posterior Vaginal Wall Repair." J Clin Anesth. 2016;34:668–75. doi:10.1016/j.jclinane.2016.07.024

10. Eng HC, Ghosh SM, Chin KJ. "Practical Use of Local Anesthetics in Regional Anesthesia." Curr Opin Anaesthesiol. 2014;27(4):382–7. doi:10.1097/ACO.0000000000000091

11. Cuvillon P, Nouvellon E, Ripart J, et al. "A Comparison of the Pharmacodynamics and Pharmacokinetics of Bupivacaine, Ropivacaine (With Epinephrine) and Their Equal Volume Mixtures With Lidocaine Used for Femoral and Sciatic Nerve Blocks." Anesth Analg. 2009;108(2):641–9. doi:10.1213/ane.0b013e31819237f8

12. Flores S, Herring AA. "Ultrasound-Guided Dorsal Penile Nerve Block for ED Paraphimosis Reduction." Am J Emerg Med. 2015;33(6):863.e3–5. doi:10.1016/j.ajem.2014.12.041

13. Dalens B, Vanneuville G, Dechelotte P. "Penile Block via the Subpubic Space in 100 Children." Anesth Analg. 1989;69(1):41–5.

14. Allan CY, Jacqueline PA, Shubhda JH. "Caudal Epidural Block Versus Other Methods of Postoperative Pain Relief for Circumcision in Boys." Cochrane Database Syst Rev. 2003;(2):CD003005. doi:10.1002/14651858.CD003005

15. Wang X, Dong C, Beekoo D, et al. "Dorsal Penile Nerve Block via Perineal Approach, an Alternative to a Caudal Block for Pediatric Circumcision — A Randomized Controlled Trial." BioMed Res Int. 2019;2019:6875756. doi:10.1155/2019/6875756

16. Aksu C, Akay MA, Şen MC, Gürkan Y. "Ultrasound-Guided Dorsal Penile Nerve Block vs Neurostimulator-Guided Pudendal Nerve Block in Children Undergoing Hypospadias Surgery." Paediatr Anaesth. 2019;29(10):1046–1052. doi:10.1111/pan.13727

17. Micali M, Cucciolini G, Bertoni G, et al. "Analgesic Strategies for Urologic Videolaparoscopic or Robotic Surgery — ESP Block Versus TAP Block." J Clin Med. 2024;13(2):383. doi:10.3390/jcm13020383

18. Shahabuddin Y, Gleeson N, Maguire PJ. "Surgeon-Administered Ilio-Inguinal and Pudendal Nerve Blocks for Major Vulval Surgery — An Observational Study With Visual Analogue Pain Scoring." Eur J Obstet Gynecol Reprod Biol. 2022;268:87–91. doi:10.1016/j.ejogrb.2021.11.429

19. Barba M, Cola A, De Vicari D, et al. "Enhanced Recovery After Surgery (ERAS) in Prolapse Repair — A Prospective Study on Pre-Emptive Uterosacral/Cervical Block." Int J Gynaecol Obstet. 2024;166(3):1240–1246. doi:10.1002/ijgo.15483