Copyright © 2017 International Anesthesia Research Society. Unauthorized reproduction of this article is prohibited. XXX XXX, 2017 • Volume XXX • Number XXX cases-anesthesia-analgesia.org 1 Copyright © 2017 International Anesthesia Research Society DOI: 10.1213/XAA.0000000000000672 R egional anesthesia improves blood fow to grafts in vascular access surgery. 1 Peripheral nerve blockade and neuraxial anesthesia techniques achieve sympa- thectomy in different ways. After peripheral nerve block- ade, autonomic blockade occurs at the level of the nerve roots and more distal portions of the nerve plexus to block neuronal output to the musculature of the arterial structures in the region of interest, and direct sympathetic blockade to the veins occurs to produce venodilation. When a neuraxial anesthesia technique is used, vasodilatory autonomic block- ade comes from direct blockade of the spinal cord, spinal nerve roots in the epidural space, and their preganglionic outfow to the thoracolumbar sympathetic chain. In periph- eral nerve and neuraxial regional anesthetic techniques, this sympathectomy results in a relatively greater contribution by the parasympathetic nervous system. In the penis, para- sympathetic innervation from the prostatic nerve plexus, originating in the intermediolateral nucleus of the spinal cord at the S2–4 level, is key for vascular relaxation via the cavernous nerves. We hypothesized potential benefts of a neuraxial anesthesia approach for the microvascular fap surgery and subsequent postoperative course of a penile allograft, while ensuring careful hemodynamic manage- ment of a patient with aortic stenosis (AS). Written consent was obtained from the patient to publish this case report. The report complies with the standards of the Health Insurance Portability and Accountability Act of 1996. Our institution’s institutional review board does not require review of case reports. CASE DESCRIPTION A 64-year-old obese man (102 kg, 69 inches, body mass index 33) with a history of moderate AS and pT3 squa- mous cell penile carcinoma cancer status post penectomy presented for penile transplantation. A recent transthoracic echocardiogram showed moderate concentric left ventricu- lar hypertrophy, preserved systolic function with an ejec- tion fraction of 70%, and an aortic valve area of 1.3 cm 2 with peak and mean gradients of 69 and 44 mm Hg, respectively. The patient was asymptomatic with an exercise capacity of >4 metabolic equivalents. The patient underwent a 16-hour surgery under com- bined regional and general anesthesia with continuous blood pressure monitoring via a radial arterial line. An epidural catheter was inserted at L5-S1 to ensure sensory blockade at the surgical site and reduce the risk of hypoten- sion. In divided doses, 6 mL of 1.5% lidocaine with 1:200,000 epinephrine (test dose ×2) and 6 mL of 2% lidocaine with 1:200,000 epinephrine were given before the induction of general anesthesia to ascertain that the neuraxial anesthetic was working. Sensory defcit was noted from above the umbilicus to the lower thighs, confrming that the catheter was in the epidural space. General anesthesia was induced with intravenous (IV) boluses of fentanyl 200 µg, lidocaine 120 mg, ketamine 35 mg, etomidate 20 mg, and cisatracurium 10 mg. Direct laryngoscopy and endotracheal intubation were uncompli- cated. After the induction of general anesthesia and before incision, an additional 6 mL of 2% lidocaine with 1:200,000 epinephrine was bolused through the epidural catheter to ensure complete sensory blockade at the surgical site, and an infusion of 2% lidocaine with 1:200,000 epinephrine was started at a rate of 4 mL/h and continued for the duration of surgery. An infusion was chosen over an intermittent bolus approach to limit hemodynamic swings and decrease man- ual labor in this lengthy case. The local anesthetic mixture contained epinephrine to help achieve a denser block and to serve as a marker against intravascular catheter migra- tion. Lidocaine was chosen over a longer-acting agent, such as bupivacaine, for its shorter half-life in the case of intra- operative hypotension becoming refractory in this patient with AS. Regional anesthesia has been used to help create local sympathectomy and improve blood fow in plastic surgery procedures involving tissue grafts and faps. However, anesthetic techniques that reduce systemic vascular resistance must be used with caution in patients with aortic ste- nosis (AS). Combined neuraxial and general anesthesia with careful titration of the local anes- thetic dose can be a safe approach for patients with AS undergoing microvascular procedures. We present the anesthetic management of the frst North American penile transplant, on an obese patient with moderate AS. (A&A Case Reports. 2017;XXX:00–00.) From the *Department of Anesthesia, Critical Care and Pain Medicine, †Plas- tic and Reconstructive Surgery, and ‡Department of Urology, Massachusetts General Hospital, Boston, Massachusetts. Accepted for publication August 28, 2017. The authors Ruscic and Zamora-Berridi contributed equally to the prepara- tion of the manuscript. Funding: None. The authors declare no conficts of interest. Address correspondence to Katarina J. Ruscic, MD, PhD, Department of Anesthesia, Critical Care and Pain Medicine, Massachusetts General Hospital, 55 Fruit St, Boston, MA 02114. Address e-mail to kruscic@partners.org. Epidural Anesthesia to Facilitate Organ Blood Flow During the First Penile Transplantation in the United States: A Case Report Katarina J. Ruscic, MD, PhD,* Grettel J. Zamora-Berridi, MD,* Francis J. McGovern, MD,‡ Curtis Cetrulo, MD,† Jonathan M. Winograd, MD,† Kyle R. Eberlin, MD,† Branko Bojovic, MD,† Dicken S. Ko, MD,‡ and T. Anthony Anderson, PhD, MD*