# APBA Kısa Özet

The KAPT block (anterior-posterior and transverse) provided significantly lower intra-procedural and 10-minute post-procedural pain than the standard paracervical block (PCB) in operative outpatient hysteroscopy, with both co-primary endpoints reaching significance. No serious adverse events occurred, and satisfaction was 100% in both arms.

# Çalışma neyi araştırdı?

This randomised controlled trial investigated whether the King's Mill Anterior-Posterior and Transverse (KAPT) block could provide better pain control than the standard paracervical block (PCB) during operative outpatient hysteroscopy. Pain control remains a significant challenge in this setting, as the PCB has shown inconsistent efficacy. The KAPT block targets the Lee-Frankenhauser plexus within the uterosacral ligament complex, an area with the highest density of uterine and cervical sensory fibres. The study aimed to determine if this targeted approach translates to improved patient comfort and reduced pain scores during and after the procedure.

# Yöntem

The study was a single-centre, participant- and outcome assessor-blinded randomised controlled trial conducted at a UK district general hospital. A total of 48 women undergoing operative outpatient hysteroscopy were randomised 1:1 to receive either the KAPT block or the PCB. Each block was delivered using 10 ml of prilocaine. Pain was measured using a 10-point Visual Analogue Scale (VAS). The co-primary endpoints were intra-procedural pain and pain measured 10 minutes post-procedure. Cervical dilatation pain was assessed as an exploratory endpoint. Analysis was performed on an intention-to-treat basis using the Mann-Whitney U test, with Hodges-Lehmann median differences and percentile bootstrap 95% confidence intervals. A hierarchical fixed-sequence testing strategy was employed.

# Temel bulgular

The results demonstrated a clear advantage for the KAPT block regarding pain control. The median intra-procedural VAS was 1 (IQR 0 to 3) with the KAPT block versus 2 (IQR 1 to 6) with the PCB. The Hodges-Lehmann median difference was -1.00 (95% CI -3.00 to 0.00; p = 0.040), indicating significantly lower pain during the procedure. At 10 minutes post-procedure, the median VAS was 0 (IQR 0 to 1.25) for the KAPT block compared to 2 (IQR 0 to 3.25) for the PCB. The median difference was -1.00 (95% CI -2.00 to 0.00; p = 0.011). Both co-primary endpoints reached significance under the hierarchical testing strategy. Notably, cervical dilatation pain, an exploratory endpoint, did not reach statistical significance (p = 0.146).

# Bulgular ne anlama geliyor?

The findings suggest that the KAPT block is an effective alternative to the standard PCB for pain management during operative outpatient hysteroscopy. By significantly reducing both intra-procedural and early post-procedural pain, the KAPT block may improve the patient experience and procedural tolerance. The consistent 100% satisfaction rate in both arms indicates that patients found both techniques acceptable, though the KAPT block achieved this with lower pain scores. The targeted nature of the KAPT block, aiming at the uterosacral ligament complex, appears to offer a more reliable pain blockade compared to the PCB.

# Klinik önem

Clinically, the KAPT block represents a meaningful advancement in pain management for operative hysteroscopy. The significant reduction in early post-procedural pain (at 10 minutes) is particularly relevant for patient recovery and comfort immediately following the procedure. The absence of serious adverse events in either group supports the safety profile of the KAPT block. Given that the study was conducted in a real-world district general hospital setting, these results could potentially influence local anaesthetic protocols and improve the overall outpatient hysteroscopy experience, although the single-centre nature means findings should be interpreted with caution regarding broader applicability.

# Sınırlılıklar

Several limitations must be considered when interpreting these results. The study was single-centre, conducted at one UK district general hospital, which limits the generalisability of the findings to other settings and populations. The sample size of 48 participants may be underpowered for some sub-group analyses. Blinding was applied to participants and outcome assessors, but the staff administering the blocks were not blinded, which could introduce some performance bias. The cervical dilatation pain was an exploratory endpoint and did not reach statistical significance (p = 0.146). Additionally, the study was not preregistered, and the risk of bias was assessed as 'some concerns'. These factors warrant that the results be viewed as preliminary and require validation in larger, multi-centre trials.