Copyright © European Society of Anaesthesiology. Unauthorized reproduction of this article is prohibited. CORRESPONDENCE Pudendal block in transurethral prostatectomy A randomised trial Taylan Akkaya, Derya Ozkan, Nihat Karakoyunlu, Julide Ergil, Haluk Gumus, Hamit Ersoy, Ayhan Comert, Halil I ˙ . Acar and Selda Yildiz From the Anesthesiology Department (TA, DO, JE, HG), Urology Department, Ministry of Health Diskapi Yildirim Beyazit Training and Research Hospital (NK, HE), Anatomy Department, Faculty of Medicine, Ankara University (AC, HIA), and Anatomy Department, Gulhane Military Medical Academy, Ankara, Turkey (SY) Correspondence to Derya Ozkan, Koru M Kavakli S. No. 4/44, 06810 Cayyolu Ankara, Turkey Tel: +903125962553; e-mail: derya_z@yahoo.com Published online 9 November 2014 Editor, Transurethral resection of the prostate (TURP) is a commonly performed surgery in the elderly male popu- lation. Neither regional anaesthesia nor general anaes- thesia is able to provide any significant postoperative analgesia of extended duration after TURP procedures due to pain resulting from the prostatic capsule, bladder spasm and catheter-related discomfort. 1 The innervation of the prostate gland is primarily due to the pelvic plexus, but neuroanatomical studies have demonstrated that the afferent fibres of the bladder can travel with the pudendal nerve. 2 Ultrasonography-guided pudendal block with a transgluteal approach is recom- mended in the prone position. 3 However, because the TURP procedure is performed in the lithotomy position, transperineal pudendal block may be a more practical approach. 4 This study aims to describe ultrasonography-guided transperineal pudendal block in TURP patients in the lithotomy position and investigate the effects of this approach on postoperative analgesia, catheter-related discomfort and patient satisfaction. Ethical approval for this study (Ethical Committee, 2011/86) was provided by the Ethical Committee Erciyes University Hospital, Kayseri, Turkey (Chairperson Prof Dr Kader Ko¨se) on 01 November 2011. To test the proposed procedure for ultrasonography- guided transperineal pudendal block in the lithotomy position, the technique was performed on two fresh cadavers. A Sonosite M turbo ultrasound machine (Bothell, Washington, USA) with a curved array trans- ducer (HFL 38x/13-6 MHz Transducer) was used to perform the pudendal block. When the ischial tuberosity was palpated, the ultrasonography transducer was placed obliquely on the ischial tuberosity. After observing the hyperechogenity of the ischial tuberosity, the transducer was moved in the medial direction to observe the sacro- tuberous ligament, which is less echogenic than bone. A total of 8 ml of 0.9% normal saline was injected over the area where the sacrotuberous ligament and ischial tuero- sity was combined. Distribution of saline to the area was observed concurrently. The needle used to perform the block was left in place and dissected to observe the nearby pudendal artery and the pudendal nerve. Written informed consent was obtained from the patients. This randomised, double-blinded, controlled study included 40 patients with an age of 50 to 75 years who were classified as American Society of Anesthesiol- ogists (ASA) I to III and undergoing TURP for benign prostate hypertrophy. The study was registered at ClinicalTrials.gov (NCT01501279). The patients were randomly allocated to two groups according to a random, computer-generated table (Group C, control; Group P, pudendal nerve block). Anaesthesia induction was achieved using 2.5 mg kg S1 of intravenous (i.v.) propofol and 1 mg kg S1 of fentanyl, a classic laryngeal mask airway (LMA) was placed. Anaes- thesia was maintained using 50% nitrous oxide in oxygen and desflurane. At the junction of the sacrotuberous ligament and the ischial tuberosity, the pudendal artery was viewed via colour flow Doppler. A 22G 100 mm Echoplex peripheral block needle (Vygon, France) was subsequently advanced just medial to the artery by using an in-plane technique (i.e. 5 cm deep to the skin, as detected in the two cadavers). The localisation of the pudendal nerve was confirmed by ipsilateral anal sphincter contraction induced using a 0.5 to 0.6 mA Plexygon nerve stimulator at 1 Hz (Vygon, Italia), and 8 ml of 0.25% bupivacaine was injected. The same procedure was applied to the other side. After the block was placed, the operation began. When the operation was complete, a 20-F urinary catheter was inserted, and the balloon was inflated with 40 ml saline. Intermittent bladder irrigation was applied for 24 h. Postopera- tive analgesia was maintained using a 20 mg PCA i.v. bolus of tramadol with a 10-min lockout period (CADD-Legacy PCA pump) (Smiths Medical, St. Paul, Minnesota, USA). Eur J Anaesthesiol 2015; 32:656–661 0265-0215 Copyright ß 2015 European Society of Anaesthesiology. All rights reserved.