Sacral Multifidus Plane Block Versus Caudal Epidural Block for Postoperative Analgesia in Pediatric Hypospadias Surgery: A Narrative Review

Abstract

Background: Hypospadias repair is one of the most common pediatric urologic procedures and is frequently associated with significant postoperative pain due to penile and perineal tissue manipulation. Effective analgesia in this population is essential not only for immediate comfort but also to reduce physiological stress, opioid exposure, and potential long-term alterations in pain processing. Caudal epidural block has traditionally been considered the gold standard regional technique for infraumbilical pediatric surgery. However, concerns related to neuraxial access and interest in ultrasound-guided, non-neuraxial alternatives have led to growing attention toward the sacral multifidus plane block as a potential alternative. This narrative review aims to compare sacral multifidus plane block and caudal epidural block for postoperative analgesia in pediatric hypospadias surgery, focusing on anatomical rationale, analgesic efficacy, safety profile, pharmacologic considerations, and clinical applicability from an anesthesia and pain management perspective.

A structured narrative synthesis of the literature was undertaken, emphasizing validated clinical studies, contemporary guidelines, and recent randomized controlled trials relevant to pediatric hypospadias repair. Caudal epidural block provides reliable sacral nerve root blockade with a long-established safety record and proven analgesic efficacy. Sacral multifidus plane block, an ultrasound-guided interfascial plane technique targeting sacral neural pathways, has emerged as a promising alternative that avoids direct neuraxial space entry. Available evidence suggests that sacral multifidus plane block can offer comparable postoperative analgesia and opioid-sparing effects, with potential advantages in terms of safety perception and technical feasibility when performed by experienced practitioners. Pharmacologic strategies using long-acting local anesthetics and adjuvants such as dexamethasone further enhance analgesic duration for both techniques.

Conclusion: Both caudal epidural block and sacral multifidus plane block are effective regional analgesic techniques for pediatric hypospadias surgery. While caudal epidural block remains the benchmark due to its extensive clinical experience, sacral multifidus plane block represents a viable and evolving alternative within multimodal analgesic pathways. Technique selection should be individualized based on surgical complexity, patient characteristics, and institutional expertise. Further high-quality, multicenter studies are warranted to refine technique standardization and optimize analgesic outcomes in this vulnerable population.