Pain, PostoperativePhase 4NCT03646006
The Effect of Pre-sacral Nerve Block on Immediate Post-operative Pain Following Laparoscopic Hysterectomy.
A Phase 4 study testing Bupivacaine in people with Pain, Postoperative, run by Mount Sinai Hospital, Canada at 1 site in Canada.
Trial summary
Hysterectomy (removal of the uterus) is the most common major gynecologic surgery performed in Canada. With a focus on minimally invasive techniques and optimization of peri-operative pain control, gynaecologists have made great strides towards reducing hospital stay and accelerating post-operative recovery. Read more about this study
- Who is it for?
- Ages 18 years and older, women only
- Conditions the study is for
- Pain, Postoperative
- What is being tested?
- Bupivacaine
- Could I receive a placebo?
- Yes, some participants may receive a placebo
- How many people
- 60 participants
- Where
- 1 siteCanada
- Study dates
- 1 Aug 2018to Jul 2019
- Phase
- Phase 4
- Are there results?
- None posted in the registry
Key requirements
Who can take part, as listed by the sponsor. Only the study team can confirm whether you are eligible, so take this list to your doctor.
- Ages 18 years and older
- Women only
- No healthy volunteers
- Adult, Older adult
Who may be able to join
- Women undergoing elective total laparoscopic hysterectomy
- Age > 18 years
Who cannot join
- Previous presacral neurectomy
- Concurrent surgical procedure other than salpingectomy and/or oophorectomy
- Gynecological cancer beyond stage 1 disease
- Chronic narcotic consumption
- Fibromyalgia
- Inability to provide consent
Trial locations and contacts
1 site in 1 country.
Canada1 site, 1 recruiting
- Recruiting
Mount Sinai Hospital
Toronto, Ontario, M5G1Z5
Mara Sobel, MD, 416-586-4800 ext. 8273, mara.sobel@sinaihealthsystem.ca
About this study
Official title: A Randomized Controlled Trial (RCT) Comparing Presacral Nerve Block Versus Sham Block on Post-operative Pain in Women Undergoing Total Laparoscopic Hysterectomy.
Hysterectomy (removal of the uterus) is the most common major gynecologic surgery performed in Canada. With a focus on minimally invasive techniques and optimization of peri-operative pain control, gynaecologists have made great strides towards reducing hospital stay and accelerating post-operative recovery. These are essential achievements, both for patients and their families and for our resource-limited public healthcare system.
Optimization of peri-operative pain control is multifactorial and includes, for example, administration of pre-operative analgesics, infiltration of incision sites with local anesthetic and provision of post-operative pain medications. As the understanding of pain mechanisms evolves, the incorporation of intra-operative nerve blocks has become yet another effective strategy to reduce post-operative pain.
Read more
The presacral nerve plexus, which carries nerve fibers from the uterus to the brain, is an important pathway that transmits midline pelvic pain in women. Destruction of the pre-sacral nerves has been shown to provide excellent pain control in a variety of clinical settings.
While transection of the presacral nerve at the time of surgery is technically challenging, instilling a presacral nerve block is surprisingly straightforward making this technique safe to perform in the hands of many gynecologists. In this technique, local anesthetic is instilled into the presacral space using a needle inserted through the abdomen.
Given that the presacral nerve plexus is an integral pain pathway for the uterus, the investigators hypothesize that the addition of a presacral nerve block during laparoscopic (camera surgery) hysterectomy would confer an additional reduction in immediate post-operative pain. The proposed study therefore aims to look at the impact of presacral nerve block versus a sham (blank) block on immediate post-operative pain in a group of women scheduled to undergo laparoscopic hysterectomy.
Read the detailed description
Objectives:
The primary objective of this study is to determine the effectiveness of a presacral nerve block on post-operative pain following total laparoscopic hysterectomy. Given that the presacral nerves carry pain sensation from the midline pelvic structures suggests that blocking this important nerve pathway intra-operatively would provide an excellent complementary method of analgesia in this patient population. Considering the frequency of hysterectomy, further improvements in pain management with this simple additional step could offer great benefits for patients and for the healthcare system by minimizing narcotic consumption, hospital stay, recovery time and time away from work.
Methodology:
This study is a single-center parallel group randomized controlled trial (RCT) comparing the administration of a presacral nerve block using 10 millilitres (mL) of local bupivacaine (5 milligrams [mg]/ml) versus 10 mL of normal saline (sham block). Participants will be selected using a convenience sample from Mount Sinai Hospital's outpatient gynecology clinics. All women undergoing total laparoscopic hysterectomy will be considered for this study. Baseline characteristics, including age, gravity, parity, medical history, surgical history, body mass index (BMI) and indication for surgery will be collected on all study participants.
Study participants will be randomized on the day of surgery. The investigators will create a randomization list using a computer-generated allocation sequence in equal ratio. The investigators will place the drug/placebo designation in numbered opaque envelopes and secure the envelope to the patient's chart on the day of surgery. The randomization number will correspond to a pre-filled syringe (containing either drug or placebo) that will be labelled with the randomization number only. A list of syringe numbers and corresponding group allocation will be kept on a secured server and will not be visible to the surgeon or study personnel. The surgeon will complete the laparoscopic hysterectomy according to his/her preferred operative technique. After the hysterectomy is completed, and prior to desufflating the abdomen, the surgeon will be presented with study drug (bupivicaine/placebo) loaded in a syringe with a spinal needle. The surgeon will laparoscopically instill the drug/placebo into the presacral space after confirming hemostasis as the final step before closing the abdomen.
The surgeon, research team, participants and data analysts will be blinded to treatment group. Participants will receive standard perioperative care including induction/maintenance of general anesthesia and prevention/treatment of post-operative nausea, vomiting and pain. Following surgery, patients will complete a self-administered visual analogue scale [VAS] for pain at 1-, 2- and 3-hours after surgery (primary outcome). In addition, the investigators will calculate total narcotic and anti-emetic consumption prior to discharge and report on any adverse events (secondary outcomes).
Outcomes:
The primary outcome will be early post-operative pain measured at 3-hours following surgery by a self-administered VAS for pain. Secondary outcome measures will include: (a) pain measured at 1- and 2-hours following surgery by a self-administered VAS for pain (b) total narcotics administered from end of surgery until discharge and (c) adverse effects/complication rates. The following will also be collected: estimated blood loss; operative time; total length of stay in post-anaesthesia recovery unit (PACU) prior to discharge; time to first void after surgery; and time to first ambulation after surgery. Due to the short follow up period for the majority of data collection, the investigators anticipate near 100% retention of study subjects.
Statistics:
Based on a sample-size calculation to detect a 30% reduction in self-reported pain using a VAS for pain (with alpha 0.05 and power 0.9) the study will require 30 patients per group. With a conservative estimate of 5 total laparoscopic hysterectomies per week, the investigators expect to surpass this target within 6 months of starting our study.
Success of the intervention will be assessed by comparing primary and secondary outcome measures between the two treatment arms using an independent student T-test (α = 0.05) for continuous variables and expressed as the difference between means with accompanying 95% confidence intervals.
- Conditions
- Pain, Postoperative
- Being tested
- Bupivacaine, Placebo
- Medical subject headings
- Pain, Postoperative
What participants receive
What participants receive. In a randomised study each person is assigned to one group by chance.
BupivacaineDrug
10 mL (5mg/mL)
PlaceboDrug
10 mL normal saline
| Study group | Role | What they receive |
|---|---|---|
| Pre-sacral nerve block | Experimental | 10 mL bupivacaine (5mg/mL) Receives: Drug: Bupivacaine |
| Sham block | Sham comparator | 10 mL normal saline Receives: Drug: Placebo |
What is being measured
The primary outcome is the main question the study is designed to answer.
Post-operative pain at 3 hours
Pain measured on a visual analogue scale (VAS). Range will be from zero (no pain) to 10 (most pain).
Measured: 3 hours post-operatively
Secondary outcomes (5)
Post-operative pain at 1 hour
Pain measured on a visual analogue scale (VAS). Range will be from zero (no pain) to 10 (most pain).
Measured: 1 hour post-operatively
Post-operative pain at 2 hours
Pain measured on a visual analogue scale (VAS). Range will be from zero (no pain) to 10 (most pain).
Measured: 2 hours post-operatively
Post-operative narcotic consumption
Total dose of narcotics consumed by the patient from end of surgery (time of extubation) until time of discharge
Measured: On day of surgery
Post-operative anti-emetic consumption
Total dose of anti-emetics consumed by the patient from end of surgery (time of extubation) until time of discharge
Measured: On day of surgery
Adverse Events
Any adverse events described during the operation, in the post-anaesthesia care unit (PACU) or reported by the patient at the 6-week post-operative visit.
Measured: 6 weeks following surgery
Timeline
From the start of the study to its completion; the mark is today. Estimated dates are the sponsor’s plan.
- First posted24 Aug 2018
- Study start1 Aug 2018
- Primary completionMar 2019 (estimated)
- Study completionJul 2019 (estimated)
Resources
- Official record on ClinicalTrials.govThe registry entry this page is built from, with its full change history.
- Other trials for Pain, PostoperativeStudies of the same condition, open and under way.
- What the trial phases meanHow a treatment moves from first tests in people to approval.
More details
For doctors and researchers: how the study is designed, who runs it, and its registry IDs.
Study design
- Study type
- Interventional
- Phase
- Phase 4
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Quadruple blind
- Who is masked
- Participant, Care provider, Investigator, Outcomes assessor
- Enrolment
- 60 participants (estimated)
Sponsor and investigators
- Lead sponsor
- Mount Sinai Hospital, Canada
- Sponsor type
- University, hospital or other
- Responsible party
- Principal investigator, Mara Sobel, Mount Sinai Hospital, Canada
- Investigators
- Mara Sobel, MD, Principal investigator, MOUNT SINAI HOSPITAL
IDs, dates and publications
- ClinicalTrials.gov ID
- NCT03646006
- Sponsor's protocol ID
- MSH REB 16-0203-A
- Status last verified
- Aug 2018
- First submitted
- 21 Aug 2018
- Last updated
- 27 Aug 2018
- Results posted
- No
- Data monitoring committee
- No
- FDA-regulated drug
- No
- FDA-regulated device
- No
- Individual data sharing
- No
Study at a glance
From the registry record, last updated by the sponsor on 27 Aug 2018. Recruitment status is as the sponsor reported it: confirm with the study team.
- Official title
- A Randomized Controlled Trial (RCT) Comparing Presacral Nerve Block Versus Sham Block on Post-operative Pain in Women Undergoing Total Laparoscopic Hysterectomy.
- ClinicalTrials.gov ID
- NCT03646006
- Acronym / sponsor ID
- MSH REB 16-0203-A
- Conditions
- Pain, Postoperative
- Phase
- Phase 4
- Study type
- Interventional
- Recruitment status
- Unknown status
- Enrolment
- 60 participants (estimated)
- Lead sponsor
- Mount Sinai Hospital, CanadaUniversity, hospital or other
- Study start
- 1 Aug 2018 (actual)
- Primary completion
- Mar 2019 (estimated)
- Study completion
- Jul 2019 (estimated)
- First posted
- 24 Aug 2018 (actual)
- Results
- Not posted in the source record
Clinical summary
The research question as the sponsor registered it. This describes what the study plans to test, not what it found.
Hysterectomy (removal of the uterus) is the most common major gynecologic surgery performed in Canada. With a focus on minimally invasive techniques and optimization of peri-operative pain control, gynaecologists have made great strides towards reducing hospital stay and accelerating post-operative recovery. These are essential achievements, both for patients and their families and for our resource-limited public healthcare system.
Optimization of peri-operative pain control is multifactorial and includes, for example, administration of pre-operative analgesics, infiltration of incision sites with local anesthetic and provision of post-operative pain medications. As the understanding of pain mechanisms evolves, the incorporation of intra-operative nerve blocks has become yet another effective strategy to reduce post-operative pain.
The presacral nerve plexus, which carries nerve fibers from the uterus to the brain, is an important pathway that transmits midline pelvic pain in women. Destruction of the pre-sacral nerves has been shown to provide excellent pain control in a variety of clinical settings.
While transection of the presacral nerve at the time of surgery is technically challenging, instilling a presacral nerve block is surprisingly straightforward making this technique safe to perform in the hands of many gynecologists. In this technique, local anesthetic is instilled into the presacral space using a needle inserted through the abdomen.
Given that the presacral nerve plexus is an integral pain pathway for the uterus, the investigators hypothesize that the addition of a presacral nerve block during laparoscopic (camera surgery) hysterectomy would confer an additional reduction in immediate post-operative pain. The proposed study therefore aims to look at the impact of presacral nerve block versus a sham (blank) block on immediate post-operative pain in a group of women scheduled to undergo laparoscopic hysterectomy.
Detailed description
Objectives:
The primary objective of this study is to determine the effectiveness of a presacral nerve block on post-operative pain following total laparoscopic hysterectomy. Given that the presacral nerves carry pain sensation from the midline pelvic structures suggests that blocking this important nerve pathway intra-operatively would provide an excellent complementary method of analgesia in this patient population. Considering the frequency of hysterectomy, further improvements in pain management with this simple additional step could offer great benefits for patients and for the healthcare system by minimizing narcotic consumption, hospital stay, recovery time and time away from work.
Methodology:
This study is a single-center parallel group randomized controlled trial (RCT) comparing the administration of a presacral nerve block using 10 millilitres (mL) of local bupivacaine (5 milligrams [mg]/ml) versus 10 mL of normal saline (sham block). Participants will be selected using a convenience sample from Mount Sinai Hospital's outpatient gynecology clinics. All women undergoing total laparoscopic hysterectomy will be considered for this study. Baseline characteristics, including age, gravity, parity, medical history, surgical history, body mass index (BMI) and indication for surgery will be collected on all study participants.
Study participants will be randomized on the day of surgery. The investigators will create a randomization list using a computer-generated allocation sequence in equal ratio. The investigators will place the drug/placebo designation in numbered opaque envelopes and secure the envelope to the patient's chart on the day of surgery. The randomization number will correspond to a pre-filled syringe (containing either drug or placebo) that will be labelled with the randomization number only. A list of syringe numbers and corresponding group allocation will be kept on a secured server and will not be visible to the surgeon or study personnel. The surgeon will complete the laparoscopic hysterectomy according to his/her preferred operative technique. After the hysterectomy is completed, and prior to desufflating the abdomen, the surgeon will be presented with study drug (bupivicaine/placebo) loaded in a syringe with a spinal needle. The surgeon will laparoscopically instill the drug/placebo into the presacral space after confirming hemostasis as the final step before closing the abdomen.
The surgeon, research team, participants and data analysts will be blinded to treatment group. Participants will receive standard perioperative care including induction/maintenance of general anesthesia and prevention/treatment of post-operative nausea, vomiting and pain. Following surgery, patients will complete a self-administered visual analogue scale [VAS] for pain at 1-, 2- and 3-hours after surgery (primary outcome). In addition, the investigators will calculate total narcotic and anti-emetic consumption prior to discharge and report on any adverse events (secondary outcomes).
Outcomes:
The primary outcome will be early post-operative pain measured at 3-hours following surgery by a self-administered VAS for pain. Secondary outcome measures will include: (a) pain measured at 1- and 2-hours following surgery by a self-administered VAS for pain (b) total narcotics administered from end of surgery until discharge and (c) adverse effects/complication rates. The following will also be collected: estimated blood loss; operative time; total length of stay in post-anaesthesia recovery unit (PACU) prior to discharge; time to first void after surgery; and time to first ambulation after surgery. Due to the short follow up period for the majority of data collection, the investigators anticipate near 100% retention of study subjects.
Statistics:
Based on a sample-size calculation to detect a 30% reduction in self-reported pain using a VAS for pain (with alpha 0.05 and power 0.9) the study will require 30 patients per group. With a conservative estimate of 5 total laparoscopic hysterectomies per week, the investigators expect to surpass this target within 6 months of starting our study.
Success of the intervention will be assessed by comparing primary and secondary outcome measures between the two treatment arms using an independent student T-test (α = 0.05) for continuous variables and expressed as the difference between means with accompanying 95% confidence intervals.
Study design
- Primary purpose
- Treatment
- Allocation
- Randomised
- Intervention model
- Parallel groups
- Masking
- Quadruple blind (participant, care provider, investigator, outcomes assessor)
- Number of arms
- 2
| Arm | Type | Receives |
|---|---|---|
| Pre-sacral nerve block | Experimental | Drug: Bupivacaine10 mL bupivacaine (5mg/mL) |
| Sham block | Sham comparator | Drug: Placebo10 mL normal saline |
Who may qualify
- Ages
- 18 years and older
- Sex
- Female only
- Healthy volunteers
- Not accepted
- Age groups
- Adult, Older adult
Key inclusion criteria (2 listed)
- Women undergoing elective total laparoscopic hysterectomy
- Age > 18 years
Key exclusion criteria (6 listed)
- Previous presacral neurectomy
- Concurrent surgical procedure other than salpingectomy and/or oophorectomy
- Gynecological cancer beyond stage 1 disease
- Chronic narcotic consumption
- Fibromyalgia
Eligibility is decided by the study team after screening; this overview does not establish that a patient qualifies. Full inclusion and exclusion criteria.
Interventions
| Intervention | Type | Arms |
|---|---|---|
| Bupivacaine10 mL (5mg/mL) | Drug | Pre-sacral nerve block |
| Placebo10 mL normal saline | Drug | Sham block |
Primary outcome
Post-operative pain at 3 hours
Time frame: 3 hours post-operatively
Pain measured on a visual analogue scale (VAS). Range will be from zero (no pain) to 10 (most pain).
5 secondary outcomes
Post-operative pain at 1 hour
Time frame: 1 hour post-operatively
Post-operative pain at 2 hours
Time frame: 2 hours post-operatively
Post-operative narcotic consumption
Time frame: On day of surgery
Post-operative anti-emetic consumption
Time frame: On day of surgery
Adverse Events
Time frame: 6 weeks following surgery
Results and safety
Results are not available in the source record.
Research links
- Official record on ClinicalTrials.govLast updated by the sponsor 27 Aug 2018.
- Individual participant dataSharing planned: No
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Referral and contact
AzTrials does not enrol participants or take referrals. Contact the study team or a site listed below; they decide who can take part. This study is not recruiting at the moment.
Mara Sobel, MD principal investigator
MOUNT SINAI HOSPITAL
1 site in 1 country: see every site and its status.
Questions about this trial
What is this clinical trial studying?
A Phase 4 study testing Bupivacaine in people with Pain, Postoperative, run by Mount Sinai Hospital, Canada at 1 site in Canada.
The full registered description is in the About this study section and the official record.
Who may be eligible to take part?
The sponsor lists 2 inclusion and 6 exclusion criteria. Eligibility is decided by the study team after screening, so read the full criteria and contact a listed site.
Is this clinical trial currently recruiting?
The record says: status not confirmed, as of the sponsor's last update on 27 Aug 2018. Status can change between updates, so confirm with the study contact before making plans.
Where is the study taking place?
The record lists 1 site in Canada. Whether a site is taking part right now should be confirmed with that site. See every site.
What are the possible benefits and risks?
They depend on the study and the treatment, and no study can promise a benefit. Some participants in this study may receive a placebo. The study team explains the known risks during informed consent, before anyone joins; the record itself does not list them.
What does this phase mean?
Phase 4 studies take place after a treatment is approved, to learn more about its long-term benefits and risks in everyday use.
Not every study follows the same path, and some studies (observational studies, device studies) have no phase.
Are results available for this study?
Results are not available in the source record.
How can a doctor refer a patient or contact the research team?
Contact Mara Sobel, MD (416-586-4800, mara.sobel@sinaihealthsystem.ca), or a site near the patient. AzTrials does not enrol participants or take referrals.
What does the primary outcome measure?
Post-operative pain at 3 hours (time frame: 3 hours post-operatively). It is what the study was designed to measure, not a finding.
Where can I read the original study information?
Does a listing mean the treatment is approved or proven to work?
No. A listing means the study is registered. It does not show that the treatment is safe, works, or is approved by a regulator.
How often is this information updated?
AzTrials copies changed records from ClinicalTrials.gov every night and reloads the whole registry every week. The sponsor last updated this record on 27 Aug 2018.