DPNB vs. Modified DPNB With Ventromedial Infiltration (DPNB According to Dalens' Technique)
DPNB vs. Modified DPNB With Ventromedial Infiltration (DPNB According to Dalens' Technique)
Dorsal penile nerve block (DPNB) is a regional nerve block probably most often performed
 throughout the world. There are several different methods described in the literature. When
 compared to penile ring wall infiltration or caudal block, the Dorsal penile nerve block
 (DPNB) is more likely associated with the risk of failure of the block quality. The aim of
 this study is to compare the quality of the standard method of Dorsal penile nerve block
 (DPNB)(Dalens' technique) with that of a modified procedure (Dorsal penile nerve block
 (DPNB)with additional infiltration of the ventromedial penis at the transition between the
 penis and the scrotum.
Male circumcision is the most often performed operation in male children throughout the
 world. In the western world it is not accepted to perform this procedure without adequate
 analgesic support. Hence the dorsal penile nerve block (DPNB), first described in the 70ies
 of the 20th century, is one of the most frequently performed regional anesthetic procedures
 in both children and adults. There are several methods described in the literature, of which
 the one described by Dalens et al in 1989 nowadays is the most often quoted and most
 frequently performed method. The reported rate of insufficient analgesia by DPNB is higher
 than caudal block or penile ring wall infiltration. It is known from neuroanatomic studies,
 that the penis is innervated mostly, but not only by the dorsal penile nerve, a final branch
 of the pudendal nerve. A varying amount of the ventral penile skin, especially of the
 preputium and the frenulum, is innervated by fine end branches of the perineal nerve, which
 otherwise gives sensoric innervation to the scrotum and motor innervation to the
 bulbospongiosus muscle. An injection of local anesthetic underneath Buck's fascia is unable
 to reach the perineal nerve, which may be the explanation for these failures.

 In this study we compare two different techniques of performing the dorsal penile nerve block
 (DPNB): the technique according to Dalens, and a modification, where a small amount of the
 local anesthetic for the dorsal penile nerve block (DPNB) is withheld, and then injected
 subcutaneously at the ventral transition between the penis and the scrotum in the midline.
 The latter injection at the site of perineal innervation is a relic of the penile ring wall
 infiltration, which surely blocks all skin fibres of both the dorsal penile nerve and the
 perineal nerve.

 All patients included randomly receive either two injections at the dorsum penis according to
 Dalens' technique, or two injections at the dorsum penis according to Dalens' technique plus
 on subcutaneous injection in the ventral midline of the penis at the transition between the
 penis and the scrotum. The amount of local anesthetic (bupivacaine 0,75%, 0,2 ml/kg of body
 weight) and dosing of narcotics (Sevoflurane 2,2 Vol% end-expiratory gas in an oxygen-air
 mixture) is the same in both groups.
Inclusion Criteria:

 -  Male infant

 -  Aged 1-17 years

 -  Elective surgery for circumcision, meatotomy or distal coronary correction of
 hypospadia

 Exclusion Criteria:

 -  Allergy to local anaesthetics

 -  Sepsis

 -  Congenital or acquired bleeding disorders

 -  Neurological disease

 -  Significant damage of central nervous system

 -  Other malformation of urethra