Hypogastric Plexus Block

Hypogastric plexus block is located bilaterally in front of the anterolateral border of the lower 1/3 of L5 vertebral body. The ganglia are located in the retroperitoneum (Plancarte et al. 1997). Superior hypogastric plexus innervates the sympathetic structures of the lower abdominal and pelvic organs. Visceral pain is an important component in pelvic pain due to cancer. Pain relief from superior hypogastric plexus block is possible because afferent nerve fibers to the pelvic structures travel via sympathetic nerves and ganglia.

Indications for Superior Hypogastric Plexus Block

Hypogastric plexus block is useful in relieving visceral pain due to cancer from the descending colon, sigmoid colon, and rectum. It is also useful in pain originating from cancer of the bladder, prostatic urethra, prostate, seminal vesicles, and testicles. Pain from the cancer of the uterus, ovary, and vaginal fundus also can be treated with hypogastric plexus block. The efficacy of neurolytic block depends on the location and extent of the tumor. It is overall considered as a good adjuvant to pain management in cancer pain from the lower GI tract and pelvic organs. The goal is to eliminate the pain or decrease it, so that concomitant oral opioid administration can control the pain without significant side effects.

Technique

Hypogastric plexus is located at the lower 1/3 of L5 vertebral body in front of the anterolateral border of L5 on each side. Two needles are usually used to approach these ganglia. Table 28.8 describes the technique of this block. Figure 28.9 shows the final position of each needle. Injection of dye is essential to show good spread of the contrast at the anterolateral border of L5 vertebral body. For diagnostic block, 8-10 ml of bupivacaine 0.25-0.5% is injected on each side. For neurolytic block, 10 ml of alcohol 100% mixed with 5 ml of lidocaine 2% (to avoid pain on injection) in each needle is administered. As an alternative, phenol 10% 8-10 ml can be injected in each needle, usually with less associated pain.

Complications

One of the serious complications is retroperitoneal hematoma which occurs more frequently in patients who are on anticoagulation at the time of the procedure. The most common

Table 28.8 Technique of hypogastric plexus block.

Position

Prone with pillow under the abdomen

Fluoroscopy use

Mandatory

Number of needles

Two

Type of needle

22G 7 in.

Level of needle insertion

Lumbar vertebrae L4-5 interspace or L5 vertebral body 7 cm from midline bilaterally

Direction of the needle

Medial and caudal toward the lower 1/3 of L5

Final position of the left needle

Lower 1/3 of L5 vertebral body in front of the anterolateral border of L5

Final position of the right needle

Same

Hypogastric Nerve Distribution

complaint after the procedure is back pain. A thorough patient history and physical examination will differentiate between back pain from needle placement or hematoma. CT scan is essential to rule out hematoma. Another common complaint is back pain which can be differentiated from back pain due to hematoma by the severity of pain and by performing serial exams. CT scan is diagnostic.

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