Efficacy of continuous epidural analgesia versus single dose caudal analgesia in children after intravesical ureteroneocystostomy.

PURPOSE: We compared the effects of single dose caudal injection and continuous epidural infusion of bupivacaine on postoperative pain intensity and supplemental opioid analgesic requirements in children undergoing intravesical ureteroneocystostomy.

MATERIALS AND METHODS: Children 6 to 18 years old scheduled for ureteroneocystostomy were recruited for the study. Patients were randomized to group 1--caudal injection of 0.25% bupivacaine before approximately surgical incision and group 2--placement of an epidural catheter with injection of 0.25% bupivacaine, followed by a continuous epidural infusion upon completion of surgery. All patients received intravenous morphine patient controlled analgesic (PCA) as a rescue analgesic, and ketorolac and oxybutynin postoperatively. The epidural catheter was discontinued 48 hours after surgery, with removal of the urinary drainage catheter 4 hours later. Outcome measures included pain intensity rating, supplemental morphine requirements, presence and pain intensity of bladder spasms, analgesia related side effects, time to tolerating a regular diet, and patient and parent satisfaction.

RESULTS: There was no statistically significant difference in average daily pain scores between the 2 groups. In the postanesthesia care unit. Significantly more patients in the caudal group required morphine than in the epidural group (56% versus 11%). The total PCA demand was significantly greater in the caudal group on days 1 and 2 postoperatively. Patients in the caudal group took significantly longer to tolerate a regular diet than those in the epidural group.

CONCLUSIONS: Continuous epidural analgesia and single dose caudal injection of bupivacaine in conjunction with intravenous morphine PCA and ketorolac provide adequate pain control following intravesical ureteroneocystostomy. Continuous epidural analgesia reduces the need for supplemental intravenous morphine and allows children to tolerate a regular diet earlier.