Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors

Urethrocutaneous fistula and glans dehiscence formation of hypospadias surgery in patients receiving caudal block vs. non-caudal block: A meta-analysis

BACKGROUND

This meta-analysis aimed to evaluate the difference in postoperative complications as urethrocutaneous fistula or glans dehiscence, in children undergoing primary hypospadias repair with caudal block (CB) versus non-caudal block (NCB).

METHODS

Data were obtained from MEDLINE, Embase, Web of Science, and the Cochrane Library. Comparative studies of CB versus NCB were identified, with reports of complications published or presented until October 2022. Subgroup analyses were performed based on study type, meatal location (distal only), type of NCB, surgeon and technique, and concentration and dose of anesthetics.

RESULTS

Compared to the reference group of NCB, CB was not significantly associated with the development of complications following primary hypospadias repair (OR 1.40, 95 % CI 0.88-2.23). After adjusting for confounding factors, such as type of study(OR 1.51, 95%CI: 0.29-7.91), type of NCB[PB (OR 1.82, 95 % CI: 0.87-3.84), GA (OR 1.26, 95 % CI: 0.39-4.04)], meatal location (distal only) (OR 1.22, 95 % CI: 0.61-2.43), surgeon and technique (OR 1.37, 95 % CI: 0.59-3.14) and concentration and dose of anesthetics(OR 2.74, 95 % CI: 0.82-9.20), subgroup analyses revealed no significant association between CB and NCB (P > 0.05).

DISCUSSION

Previous studies have found a correlation between CB and increased incidence of postoperative complications (urethrocutaneous fistula or glans dehiscence) of hypospadias, but different literature have suggested that surgical technique, surgical duration and the severity of hypospadias, rather than CB, are closely related to the occurrence of complications. In order to reduce confounding factors, subgroup analyses were conducted. The results showed that no correlation could be found in postoperative complications and CB.

CONCLUSIONS

This meta-analysis compared the incidence of urethrocutaneous fistula or glans dehiscence in the CB and NCB groups for primary hypospadias repair in children, indicating that no clear correlation could be found in postoperative complications and CB. Subgroup analyses on study type, type of NCB, meatal location (distal only), surgeon and technique, and regional anesthetic concentration and dose supported this conclusion.

Intravenous dexamethasone does not prolong the duration of pudendal nerve block in infants and children undergoing hypospadias surgery: A randomized clinical trial

BACKGROUND

The administration of intravenous dexamethasone increases the duration of neuraxial block and improves the quality of analgesia. However, little is known about these effects of dexamethasone on peripheral nerve blocks in children.

AIMS

In this study, we aimed to investigate the benefit of intravenous dexamethasone for enhancing the effect of pudendal block on postoperative analgesia in children who underwent hypospadias surgery.

METHODS

In total, 46 children aged 6-36 months who underwent hypospadias surgery were randomly allocated to either a control group (normal saline, group C) or dexamethasone group (0.5 mg/kg, group D). Pudendal block was performed before the surgery using 0.3 mL/kg of 0.225% ropivacaine on both sides. Parents were instructed to press the patient-controlled analgesia bolus button when their children's pain score was >4 points. The primary outcome measure was the time at which the first patient-controlled analgesia by proxy bolus dose was administered. The secondary outcome measures were pain score, number of patient-controlled analgesia administration by proxy bolus attempts, number of rescue analgesics required, total amount of fentanyl administered, and overall parental satisfaction.

RESULTS

The time of first patient-controlled analgesia bolus administration by proxy was not different between the control and dexamethasone groups (5.6 [5.2, 8.8] h versus 6.5 [5.4, 8.1] h, hazard ratio 0.8, 95% confidence intervals 0.43 to 1.47, p = .46). There were no statistically significant differences among the secondary outcomes.

CONCLUSIONS

Administration of intravenous dexamethasone did not enhance the duration of pudendal nerve block in infants and children aged 6-36 months who underwent hypospadias surgery.

Does local injection of long acting corticosteroid improve postoperative outcome of hypospadias repair? A randomized controlled trial

PURPOSE

To assess the safety and efficacy of local corticosteroid injection during hypospadias repair.

METHODS

Between May 2021 and March 2023 children less than 10 years who were admitted for hypospadias repair were divided by random allocation into two groups. We injected local corticosteroid 2 ml proximal to coronal sulcus in group A while in group B we didn't. All types of hypospadias were included in the study. We excluded patients older than 10 years and those with pre-existing complicated hypospadias (multiple fistulae and multiple surgeries), or bleeding diatheses. Pre-operative, intraoperative and postoperative variables were compared between the two groups.

RESULTS

A total of 120 patients (60 in each group) were enrolled in the study. The mean ages and preoperative variables were not significantly different. The site of hypospadias and the type of surgery were comparable in both groups. (Table) There were no significant differences between both groups regarding average blood loss and operative time in each type of surgical repair. There was a significant higher incidence of intraoperative and postoperative penile oedema in group B (P-value < 0.001) while the incidence of skin discolouration was higher in group A. Postoperative complications, described as Clavian classification, were significantly higher in group B. The incidences of superficial skin infection, meatal stenosis, urethral fistula, and recurrence with the need for redo repair were significantly higher in group B (P-value: 0.002, 0.018, 0.032, and 0.001, respectively).

CONCLUSION

Local corticosteroid injection during hypospadias repair minimize the penile oedema and decrease the incidence of postoperative functional and cosmetic complications.

Caudal anesthesia is not associated with post-operative complications following distal hypospadias repair

INTRODUCTION

The use of caudal anesthesia at the time of hypospadias repair remains controversial as some prior studies have reported increased postoperative complication rates associated with caudal nerve block. However, these results have been called into question due to confounding factors and heterogeneous study groups.

OBJECTIVE

Given the importance of identifying true risk factors associated with increased hypospadias complication rate, we examined our experience with caudal anesthesia limiting our analysis to distal repairs. We hypothesized that caudal anesthesia would not be associated with increased postoperative complications.

STUDY DESIGN

We retrospectively reviewed our institutional hypospadias database from June 2007 to January 2021. All boys who underwent single-stage distal hypospadias repair with either caudal or penile block with minimum 1 month follow up were included. Records were reviewed to determine the type of local anesthesia, type of hypospadias repair, all complications, and time to complication. Association between any complication and local anesthesia type was evaluated by univariate and multivariate logistic regression analysis controlling for age at surgery and type of repair. A sub-analysis was performed for complications occurring ≤30 days.

RESULTS

Overall, 1008 boys, 832 (82.5%) who received caudal and 176 (17.5%) penile block, were included. Median age at surgery was 8.1 months and median follow up was 13 months. Overall complication rate was 16.4% with 13.8% of patients requiring repeat operation. Median time to complication was 10.59 months and was significantly shorter in the caudal group (8.45 vs. 25.2 months). Caudal anesthesia was associated with higher likelihood of complication on univariate analysis; however, this was not true on multivariate analysis when controlling for age and type of repair. Caudal anesthesia was not associated with increased likelihood of complication within 30 days.

DISCUSSION

Since the association between caudal anesthesia and hypospadias complications was first suggested, several studies have tried to answer this question with variable results. Our findings add to the evidence that there is no association between caudal anesthesia and increased hypospadias complications in either the short or long term. The major strengths of our study are a large, homogenous study population, robust follow up and inclusion of data from 14 surgeons over 14 years. Limitations include the study's retrospective nature as well as lack of standardized follow up protocol throughout the study period.

CONCLUSIONS

After controlling for possible confounders, caudal nerve block was not associated with increased risk of postoperative complications following distal hypospadias repair.

Nerve stimulation guided bilateral pudendal nerve block versus landmark-based caudal block for hypospadias repair in young children: a prospective, randomized, pragmatic trial

Introduction

Caudal block is frequently performed to provide analgesia for hypospadias repair. Literature suggests that pudendal block provides prolonged postoperative analgesia as compared with caudal block in children between 2 and 5 years. We compared the efficacy of pudendal and caudal blocks in children less than 2 years.

Methods

60 children scheduled for hypospadias repair received standard general anesthesia along with either pudendal or caudal block (groups of 30 each). Variables collected were demographic data, block time, operating room time, intraoperative pain medication need, pain assessment score and medication need in the recovery room and pain assessment at home.

Result

Groups were demographically similar. No differences were observed in the following recorded times (minutes): block procedure (caudal: 9.5±4.0, pudendal: 10.6±4.1, p=0.30), anesthesia (caudal: 17.3±5.3, pudendal: 17.7±4.3, p=0.75), total OR (caudal: 171±35, pudendal: 172±41; p=0.95) and postanesthesia care unit (PACU) stay (caudal: 88±37, pudendal: 86±42; p=0.80). Additionally, no differences were observed in rescue pain medication need in the operating room (caudal: 0, pudendal: 2 (p=0.49), in PACU (caudal: 4, pudendal: 4, p=0.99), pain assessed at home, time to pain level 2 (caudal: 13.93±8.9, pudendal: 15.17±8.7), average pain scores (p=0.67) and total pain free epochs (pain level of zero) (p=0.80) in the first 24 hours.

Discussion

In children less than 2 years, both blocks provide comparable intraoperative and postoperative pain relief in the first 24 hours after hypospadias surgery.

Trial registration number

NCT03145415.

Evolving approaches in neonatal postoperative pain management

Neonates experience significant moderate and severe postoperative pain. Effective postoperative pain management in neonates is required to minimize acute and long-term effects of neonatal pain. Protecting the developing nervous system from persistent sensitization of pain pathways and developing primary hyperalgesia is essential. Opioids and acetaminophen are commonly analgesics used for pain control. Regional anesthesia provides adequate intraoperative and postoperative analgesia in neonates. It decreases exposure to opioids, reduces adverse drug effects, and facilitates early extubation. It suppresses the stress response and can prevent long-term behavioral responses to pain. The most common blocks performed in neonates are neuraxial blocks. Using ultrasound increased the number of peripheral nerve blocks performed in neonates. Recently, various peripheral nerve blocks (paravertebral, transverse abdominis plane, rectus sheath, quadratus lumborum, erector spinae plane blocks) were safely used. Many studies support analgesic efficacy but highlight neonates' unpredictability and variability of fascial blocks.

Effects of Caudal and Penile Blocks on the Complication Rates of Hypospadias Repair

Background:

The major influencing factors for complications during hypospadias repair are the original location of the meatus, previous urethral surgery, surgical technique, and surgeon’s experience. While the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.hile the effect of the technique of regional analgesia on complication rates has been considered in some studies, this issue remains controversial.

Aims:

To determine the effect of caudal block and penile block on complication rates of hypospadias repair in patients with subcoronal hypospadias.

Study Design:

Retrospective cross-sectional study.

Methods:

Data of children who underwent hypospadias repair between 2011 and 2019 in our clinic (n = 770) were reviewed retrospectively. Only patients with subcoronal hypospadias and who underwent tubularized incised plate urethroplasty, performed by the same two experienced surgeons (n = 279), were included in the study. The exclusion criteria were incomplete data and follow-up time shorter than 12 months. Data of 279 patients were analyzed. Patients were divided into two groups according to the analgesia type: caudal block (n = 95) and penile block (n = 184), and complication rates were compared between these groups.

Results:

The median age was 36 months in the caudal block group and 30 months in the penile block group (P = 0.390). The median follow-up times were 54 and 42.7 months in the caudal and penile block groups, respectively. Total complication rates did not differ significantly between the groups and were determined as 10.5% and 12.5% in the caudal and penile groups, respectively. Urethrocutaneous fistula rates were observed as 2.1% and 4.3% (p=0.50). None of the patients had penile chordee and no penile plication was performed in the whole group.

Conclusion:

This study shows that there is no increase in post-repair complications in patients with subcoronal hypospadias who underwent caudal block.

Incidence of urethrocutaneous fistula following distal hypospadias repair with and without caudal epidural block: A randomized pilot study

INTRODUCTION

Recent investigations have raised a doubt regarding the safety of Caudal epidural block (CEB) administered to children with distal hypospadias undergoing tubularised incised plate (TIP) urethroplasty. The primary objective of the study was to investigate whether there is any association between CEB and the occurrence of urethrocutaneous fistula (UCF) in the postoperative period.

METHODS

Fifty ASA 1 and 2 children with distal hypospadias aged 0-8 years were randomly allocated to CEB group (GA with CEB, 0.2% ropivacaine 1 ml/kg; n = 25) and Non-CEB group (GA without CEB; n = 25). Penile measurements were taken before and 20 min after administration of CEB to assess penile engorgement. Intraoperative hemodynamics were recorded at 10 min intervals after induction of anaesthesia. Consumption of IV fentanyl intraoperatively and postoperatively in first 24 h was recorded in both the groups. Rescue analgesia was administered for a score >4 on FLACC scale. After surgery children were followed up monthly for first three months and then at 6-months and yearly in paediatric surgery OPD to assess for development of UCF.

RESULTS

UCF was found to occur in only two children, one from each group on follow up, with an overall incidence of 4%. There was no difference in the incidence of UCF in the patients with and without CEB. A 26.8% increase in penile volume from baseline was recorded in CEB group (P = 0.000). The intraoperative heart rate and mean arterial pressure was significantly lower in the CEB group as compared to non CEB group at various time intervals. No additional intraoperative IV fentanyl supplementation was required in CEB group. Fentanyl consumption was significantly less in CEB group postoperatively in first 24 h (P = 0.000).

DISCUSSION

Administration of CEB was not found to have any impact on UCF formation. No relationship between the increase in penile volume after CEB block and occurrence of UCF was noticed.

CONCLUSION

Despite increase in penile volume after CEB, there was no difference between the two groups as regards to the occurrence of post operative UCF. CEB is an effective analgesic modality and can be continued to be used till the results of well powered prospective randomised trials with long follow up are reported.

The effect of caudal epidural block on the surgical complications of hypospadias repair in children aged 6 to 35 months: A randomized controlled trial

BACKGROUND

Caudal epidural block (CEB) in hypospadias surgery has the benefit of reducing post-operative pain and possibly intra-operative bleeding. Some studies, however, have suggested that this technique may increase the rate of post-operative complications. Considering the uncertainty about the effect of CEB on surgical complications of hypospadias repair, the current study was performed.

OBJECTIVE

The aim of this randomized clinical trial was to compare the complication rates between patients who receive CEB after hypospadias surgery and those who did not.

STUDY DESIGN

This double-blind randomized controlled trial was conducted on boys aged 6-35 months, who underwent hypospadias repair surgery in a university hospital from March 2018 to March 2019. Sixty patients were randomly divided into two groups (group A: 31 and group B: 29). In group B, CEB was performed, using 0.5 mg/kg of 0.125% bupivacaine (Marcaine). Postoperative complications including fistula, meatal stenosis, dehiscence, and occurrence of bleeding were assessed during six months after surgery.

RESULTS

The patients were assessed for possible complications at 24 h, one week, one, three and six months after surgery. No remarkable differences were observed between the patients in the two groups in terms of the frequency of dehiscence, fistula, and meatal stenosis (P > 0.05). Moreover, the difference in complication rates between the patients with proximal and distal hypospadias did not reach statistical significance (P = 0.549).

DISCUSSION

Assessment of complications showed no significant difference between the two study groups in terms of dehiscence, fistula, and meatal stenosis (Clavien type III). In addition, complication rate was not significantly different according to severity of hypospadias between the two groups. Our study had limitations such as short follow up and small sample size, which resulted in insignificant difference in complication rate between proximal and distal hypospadias. These limitations request large studies with long term follow up.

CONCLUSION

The current study showed that the use of caudal block anesthesia in comparison with general anesthesia did not increase surgical complications, which approved CEB protocol as a safe method in hypospadias repair.

The association between caudal block and urethroplasty complications of distal tubularized incised plate repair: experience from a South China National Children's Medical Center

Background

The effect of caudal block (CB) on the incidence of urethroplasty complications in hypospadias repair remains controversial. The evidence is conflicting, and some confounding bias issues need to be addressed. We sought to study a more homogenous group of distal hypospadias patients undergoing primary tubularized incised plate (TIP) repair by a senior pediatric urology surgeon in the past 2 years to examine the relationship between urethroplasty complications and the use of CB.

Methods

We reviewed our database to identify consecutive patients who had undergone hypospadias repairs by a senior director surgeon at our Center between January 2018 and November 2020. To be eligible to participate in the study, patients had to meet the following inclusion criteria: (I) have distal hypospadias; (II) have undergone a primary TIP repair; and (III) have attended follow-up appointments for a minimum period of 6 months. The primary outcome was the development of urethroplasty complications during the follow-up period. The principal variable of interest was whether or not CB was used perioperatively. The patients were categorized into a CB group (general anesthesia combined with CB) or a control group (general anesthesia only). Other potential risk factors were analyzed, including patient age at operation, patient weight, glans width, and the length of the urethral plate defect.

Results

Thirty (12.2%) of the distal patients developed postoperative surgical complications. The postoperative surgical complication rates were similar between the different anesthesia groups. Weight, the length of the urethral plate length, and glans width did not contribute to the risk. Age was the only independent risk factor for postoperative surgical complications, and the complication rates increased in older patients.

Conclusions

Our data from consecutive TIP repairs in distal hypospadias patients indicated no association between the use of CB anesthesia and the postoperative urethroplasty complication rate. Patients who were older in age when they underwent surgery had a higher risk of complications.

A comparative study of polydioxanone (PDS) and polyglactin (Vicryl) in hypospadias repair

BACKGROUND

Hypospadias is a fairly common problem, and it is the most common genital congenital anomaly.

OBJECTIVE

This study was carried out to compare polyglactin and polydioxanone in hypospadias repair by assessing the rate of complications, especially urethrocutaneous fistula (UCF) formation.

PATIENTS AND METHODS

This is a prospective observational cross-sectional hospital-based study carried out at the Department of Paediatric Surgery, Ribat University Hospital, from June 2015 to November 2016. In Group A, there were 55 patients who underwent repair using polyglactin, and in Group B, there were 50 patients who underwent repair using polydioxanone. All patients were operated by the same surgeon.

RESULTS

The mean age of Group A was 5.7 ± 4.3 years and 5.1 ± 3.9 years in Group B. Meatal advancement and glanuloplasty incorporated operation was done in 47.6%, Tubularized incised plate urethroplasty in (31.4%), Theirsch-Duplay in 20% and Mathieu's repair in 1%. The complication rate was 34% in Group A and 10.9% in Group B. The most frequent complication was UCF, as 19 patients (18.1%) of the study candidates developed UCF; most of them were in Group A (14 patients) and 5 patients in Group B. Another significant complication was meatal stenosis, which occurred in 11 patients (10.5%): 9 in Group A and 2 in Group B.

CONCLUSION

Polydioxanone (PDS) is satisfactory in hypospadias repair as it is associated with better outcome, especially UCF, which is most common and most difficult to treat complication.

Dorsal penile block versus caudal epidural anesthesia effect on complications post-hypospadias repair: Dilemmas, damned dilemmas and statistics

The evidence examining the effects of regional blocks on complications posthypospadias repair has been controversial. Nine observational studies have been published thus far, with inconsistent and somewhat contradictory results. In this educational article, we attempt to explain the concepts of study accuracy and precision in the context of the hypospadias literature to shed some light on the reasons behind those controversies. Methodological issues such as selection bias, confounding effect, sample size, confidence interval and study generalizability from studies involving dorsal penile block versus caudal epidural anesthesia in hypospadias repair are discussed.

Penile nerve block predicts higher revision surgery rate following distal hypospadias repair when compared with caudal epidural block: A consecutive cohort study

INTRODUCTION

Recent literature has suggested caudal epidural blocks (CEB) may increase revision surgery rates following hypospadias repair. We sought to investigate this using a large, multi-surgeon series.

OBJECTIVE

The primary objective of this study was to identify the impact of CEB or penile nerve blocks (PNB) on revision surgery rates following distal hypospadias repair at our centre.

STUDY DESIGN

A prospectively maintained database of consecutive patients undergoing primary hypospadias repairs under the supervision of 8 different paediatric surgeons at our centre between January 2015 and December 2018 was queried for the following potential risk factors: Age at surgery, American Society of Anaesthesiologist's (ASA) grade, hypospadias type, type of surgery, CEB or PNB, and training level of primary surgeon. Revision surgery was defined as reoperation for fistulas, dehiscence, strictures or meatal stenosis. Univariate and Multivariate analysis was performed using logistic regression.

RESULTS

188 patients underwent primary distal hypospadias repair over the study time period. Patients were aged between 7 months and 15 years of age. Median age at surgery was 14 months. Revision surgery was performed for 31 patients (16.5%). Indications were urethrocutaneous fistula (n = 17, 9.0%), meatal stenosis or stricture (n = 9, 4.8%) and glans dehiscence (n = 5, 2.7%). 114 (60.6%) received a penile block and 74 (39.4%) a caudal block. On univariate analysis, PNB (HR 2.55 95% CI 1.04-6.27, p = 0.04) was statistically significant for revision surgery. This association remained significant on multivariate analysis (HR 2.74 95% CI 1.09-6.92, p = 0.03). All other prognostic factors examined were not statistically significant for revision surgery.

DISCUSSION

Our findings suggest PNB are associated with higher revision surgery rates following distal hypospadias repair. This contrasts with the findings of other authors.

CONCLUSION

Our study is the first to demonstrate an association between PNB and higher revision surgery rates following distal hypospadias repair.

Risk factors for urethrocutaneous fistula following hypospadias repair surgery in Indonesia

INTRODUCTION

Hypospadias is one of the most common congenital malformations with a worldwide increasing trend over the years. Despite advancements in hypospadias repair, complications still occur. One of the most common complications of hypospadias repair surgery is Urethrocutaneous fistula. Studies attempting to analyze the association between the complication and risk factors are always beneficial, especially for studies performed in different areas of the world. We hypothesize that several evaluated risk factors among Indonesian hypospadias patients could be associated with the occurrence of urethrocutaneous fistula after the repair procedure.

OBJECTIVE

To determine the risk factors associated with urethrocutaneous fistula after hypospadias repair surgery by collecting and analyzing data obtained from multiple centers in Indonesia.

MATERIALS AND METHODS

A nationwide, retrospective study with 12 hospitals in Indonesia of children with a diagnosis of hypospadias was conducted. The collected data, taken from patients admitted in 2018, from each center's medical records consisted of patient identity, repair technique used, neourethra length, percutaneous cystostomy, and splint size as independent variables speculated to be possible risk factors correlated to the presence of urethrocutaneous fistulae. Binomial logistic regression analysis was performed using SPSS 21.0 to determine the relationship between urethrocutaneous fistulae as a post-repair complication and possible risk factors.

RESULTS

We collected 591 hypospadias cases from 12 centers in 9 cities in Indonesia. Most patients came when they were already at the age of more than four years old (60.4%). The chordee-only and failed urethroplasty groups are excluded from the analysis as they are not classified as true hypospadias. Most repairs were performed by using the Tubular Incised Plate (TIP) with Thiersch-Duplay technique (44.16%). Most of the reconstructed neourethra are 2-3 cm in length (32.13%). The 8 Fr urethral splint (46.41%) was mostly used during the operation. Most surgeons decided not to perform cystostomy throughout the procedure (61.03%) based on personal preferences. Urethrocutaneous fistula was found in 80 patients (15.27%) out of the total patients who underwent the surgery. The binomial logistic regression analysis shows that age (OR = 1.398, p = 0.015), the decision to not perform cystostomy (OR = 2.963, p = 0.014), and splint size (OR = 1.243, p = 0.023) are significantly associated (p < 0.05) with the development of urethrocutaneous fistula.

CONCLUSION

Age and splint size are significant risk factors for urethrocutaneous fistula after hypospadias repair in Indonesia, whereas performing percutaneous cystostomy during the repair decreases the risk for urethrocutaneous fistula occurrence.

Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis

BACKGROUND AND OBJECTIVES

is commonly used for children undergoing hypospadias repair. However, the safety of caudal block for hypospadias repair in children is controversial in terms of surgical complications such as urethrocutaneous fistula and glans dehiscence. We sought to perform a meta-analysis to estimate the analgesic efficacy and relative complications of caudal block for hypospadias repair in children.

METHODS

We identified comparative studies of caudal block versus peripheral nerve block or no caudal block; studies were published or presented through 1 January 2018, and reports of analgesic efficacy or surgical complications of hypospadias repair in children were identified. Peripheral nerve block includes dorsal nerve penile block and pudendal nerve block. Data were abstracted from studies comparing caudal block with peripheral nerve block or no caudal block; original source data were used when available. We prespecified separate assessments of randomized controlled trials (RCTs) and observational studies given the inherent differences between types of study designs. Data from 298 patients in four RCTs and from 1726 patients in seven observational studies were included. RCT and observational data were analyzed separately.

RESULTS

In RCTs, caudal blocks (compared with peripheral nerve blocks) showed no detectable differences in terms of need for additional analgesia within 24 hours after the surgery (OR 10.49; 95% CI 0.32 to 343.24; p=0.19), but limited data showed lower pain scores 24 hours after the surgery (standardized mean difference (SMD) 1.57; 95% CI 0.29 to 2.84; p=0.02), a significantly shorter duration of analgesia (SMD -3.33; 95% CI -4.18 to -2.48; p<0.0001) and analgesics consumption. No significant differences were observed in terms of postoperative nausea and vomiting (OR 3.08; 95% CI 0.12 to 77.80; p=0.50) or motor weakness (OR 0.01; 95% CI -0.03 to 0.05; p=0.56). Only one randomized study showed that caudal blocks (compared with peripheral nerve blocks) were associated with detectable differences in urethrocutaneous fistula rate (OR 25.27; 95% CI 1.37 to 465.01; p=0.03) and parental satisfaction rate (OR 0.07; 95% CI 0.02 to 0.21; p<0.00001). In observational studies, caudal block was not associated with surgical complications in all types of primary hypospadias repair (OR 1.83; 95% CI 0.80 to 4.16; p=0.15). To adjust for confounding factors and to eliminate potential selection bias involving caudal block indication, we performed subgroup analysis including only patients with distal hypospadias. This analysis revealed similar complication rates in children who received a caudal block and in children not receiving caudal block (OR 1.02; 95% CI, 0.39 to 2.65; p=0.96). This result further confirmed that caudal block was not a risk factor for surgical complications in hypospadias repair. The direction of outcomes in all the other subgroup analyses did not change, suggesting stability of our results.

CONCLUSIONS

In RCTs, only limited data showed peripheral nerve blocks providing better analgesic quality compared with caudal blocks. In real-world non-randomized observational studies with greater number of patients (but with admitted the potential for a presence of selection bias and residual confounders), caudal blocks were not associated with postoperative complications including urethrocutaneous fistula and glans dehiscence.

A Review of Regional Anesthesia in Infants

Regional anesthesia provides effective anesthesia and pain relief in infants with age-specific data attesting to safety and efficacy. Regional anesthesia decreases exposure to opioids and general anesthetic agents and associated adverse drug effects, suppresses the stress response, and provides better hemodynamic stability compared to general anesthesia. Regional anesthesia can prevent long-term behavioral responses to pain. As a result, the overall number and variety of nerve blocks being used in infants is increasing. While neuraxial blocks are the most common blocks performed in infants, the introduction of ultrasound imaging and a better safety profile has advanced the use of peripheral nerve blocks. Infant-specific pharmacokinetic and pharmacodynamic data of local anesthetic medications are reviewed including risk factors for the accumulation of high serum levels of unbound, pharmacologically active drug. Bupivacaine accumulates with continuous infusion and 2-chloroprocaine can be used as an alternative. Local anesthetic systemic toxicity has the highest incidence in infants less than 6 months of age and is associated with bolus dosing and penile nerve blocks. Local anesthetic toxicity is treated by securing the airway, suppression of seizure activity and implementation of cardiopulmonary resuscitation. Administration of intralipid (intravenous lipid emulsion) is initiated at the first sign of toxicity. A high level of expertise in regional anesthesia is needed when treating infants due to their unique development.

Postoperative complications of hypospadias repair in patients receiving caudal block vs. non-caudal anesthesia: A meta-analysis

INTRODUCTION

We performed a meta-analysis of the current literature to assess the association of caudal block and postoperative complication rates following hypospadias repair.

METHODS

A Systematic literature search was conducted on October 2017. Five reviewers independently screened, identified, and evaluated comparative studies assessing postoperative outcomes following hypospadias repair with and without caudal block. The incidence of post-surgical complications from each study was extracted for caudal block and control groups to generate the odds ratio (OR) and corresponding 95% confidence intervals (CI). Effect estimates were pooled using inverse-variance method with random-effects model. Subgroup analyses were performed according to study type and hypospadias severity.

RESULTS

Nine studies (2096patients) of low- to moderate-quality were included for meta-analysis. Overall pooled effect estimates demonstrated increased occurrence of postoperative complication rates among patients with caudal block (OR 2.32; 95% CI 1.29-4.16). Subgroup analysis according to hypospadias severity revealed that a significant increased OR in complication rate was noted among proximal hypospadias (OR 3.55; 95% CI 1.80-7.01), but not distal hypospadias (OR 1.31; 95% CI 0.59-2.88).

CONCLUSIONS

Our meta-analysis of poor-quality evidence may have revealed a significant association between caudal block and postoperative complications following hypospadias repair. However, subgroup analysis demonstrated that hypospadias severity is important in determining complication rates, suggesting that confounding factors and selection bias may play a central role in characterizing the true effect of the anesthesia approach.

Does caudal analgesia increase the rates of urethrocutaneous fistula formation after hypospadias repair? Systematic review and meta-analysis

INTRODUCTION

Caudal block analgesia is administered to lower the requirements of systemic and inhaled anesthetic drugs during hypospadias surgery. However, recent reports, all clustered in a short time-span have generated controversial and mutually opposing results while evaluating caudal block as an independent risk factor for urethroplasty-related complications after hypospadias repair. There is no consensus statement on the role of caudal block analgesia in formation of urethrocutaneous fistula (UCF) after hypospadias surgery. We performed a systematic review and meta-analysis of the studies evaluating the relative rates of UCF formation after hypospadias surgery in patients who were administered caudal block analgesia versus in those who were not.

METHODS

Electronic searches were performed using PubMed, PubMed Central, Google Scholar, Ovid, and the Cochrane library. Statistical analysis was performed using a fixed-effect model, odds ratios, risk ratios (RR), and heterogeneity (I2) were calculated. Funnel plot was used to assess for publication bias.

RESULTS

Seven studies with 1706 patients were included. Caudal block analgesia is associated with a significantly higher risk of UCF formation (RR: 1.81; 95% confidence interval [CI]: 1.30-2.53), (P = 0.0004) and other urethroplasty-related complications (RR 2.01; 95% CI: 1.48-2.74), (P < 0.00001) after hypospadias surgery. Funnel plots indicate some publication bias.

CONCLUSIONS

In patients undergoing hypospadias repair, administration of caudal analgesia is associated with a higher risk of UCF formation and other urethroplasty-related complications.

Effect of anesthesia for hypospadias repair on perioperative complications

BACKGROUND

Recent publications from the United States, India, and Korea report that children undergoing hypospadias repair with caudal regional anesthesia/analgesia could have increased postoperative surgical complications.

AIMS

The purpose of this retrospective cohort study was to assess the impact between caudal regional anesthesia, other regional anesthesia, and no regional anesthesia on complications after hypospadias repair at a tertiary care children's hospital in Ottawa, Canada, with an expectation to changing practices if a link was found.

METHOD

We reviewed the health records of 827 children with hypospadias undergoing penile surgery from January 1991-June 2017. The final sample size for the analysis consisted of 764 patients and 825 procedures.

RESULTS

The overall complications were almost identical when considering anesthesia effects, and this similarity persisted when we assessed specifically for only surgical complications. We had 716, 94, and 15 subjects who had a caudal block, penile block, and general anesthesia only, respectively, and their complication rates were 28, 31, and 27%, respectively, and their fistula formation rates were 10, 6, and 0%, respectively, and their stricture formation rates were 8, 7, and 20%,, respectively. Hypospadias type and surgical repair technique were marked predictors of complications in the postoperative period.

CONCLUSION

Anesthesia technique appears to have minor impact on complications after hypospadias repair, while surgical technique and type of hypospadias impact complications after hypospadias surgery in children. Based upon these results, we will not change our current practice of using a variety of regional anesthesia techniques for children undergoing hypospadias repair.

Anesthesia in the Pediatric Patient

Improvements in anesthetic drugs and monitoring techniques over the past several decades have significantly reduced the anesthetic risks for pediatric patients. Neonates and infants are at increased risk for cardiovascular and pulmonary complications, and recent reports have led to concern that these young patients may be at risk for long-term detrimental neurodevelopmental effects as well. Although studies are currently under way to answer the question of anesthetic neurotoxicity in children, surgeons and anesthesiologists must work with parents to determine the best course of action for these vulnerable patients.

Autologous granulation tissue tubes for replacement of urethral defects: An experimental study in male rabbits

INTRODUCTION

Tubularized urethroplasty is commonly performed in clinical practice using genital skin flaps, bladder mucosa, and buccal mucosa. However, the long-term effects are not satisfying, and donor site morbidities remain a problem. Besides, those grafts are unavailable with malignant conditions of the urinary tract, a history of lichen sclerosis, or oral disease.

OBJECTIVE

An autologous granulation tissue tube of any required length and diameter can be produced by implanting foreign objects subcutaneously (Summary Fig.). The current study aimed to investigate to what extent of length this fully autologous tissue could be used for tubularized urethroplasty, satisfying urethral patency and tissue regeneration, in male rabbits.

STUDY DESIGN

Twenty-seven New Zealand male rabbits were randomly divided into three groups. Silastic tubes were implanted subcutaneously in Group 1 and Group 2. By 2 weeks the granulation tissue encapsulating the tubes was harvested. In Group 1, pendulous urethral segments of 1 cm were excised, and urethroplasty was performed with the granulation tissue tube in an end-to-end fashion. In Group 2, a pendulous urethral segment of 1.5 cm was replaced with the tissue tube. In Group 3, a pendulous urethral defect of 1 cm was repaired by re-anastomosis as control. Serial urethrograms were performed at 1, 2 and 6 months postoperatively. Meanwhile, the neo-urethra were harvested and analyzed grossly and histologically.

RESULTS

The urethrograms showed that all animals in Group 1 maintained a wide urethral caliber. In contrast, animals in Group 2 and Group 3 developed progressive strictures. Histologically, an intact urothelium with one to two cell layers lined the graft by 1 month, which was surrounded by increasing organized smooth muscle in Group 1. By 6 months, the grafts were completely integrated into native urethra. Nevertheless, extensive fibrosis occurred in Group 2 and Group 3.

DISCUSSION

The tissue successfully maintained patency and guided urethral regeneration across a distance of 1 cm. As an epithelium-free graft, the tissue showed better results than acellular matrix for tubularized urethroplasty compared with previous studies. Nevertheless, several limitations existed: (1) the urethral defect was created in healthy urethra, which could not fully simulate the clinical situation; (2) as a small animal model, rabbit was less informative for clinical problems; (3) the tissue was inadequate for long segmental urethral replacement. Further study is needed before the procedure is used clinically.

CONCLUSION

An autologous granulation tissue tube grown subcutaneously could be successfully used to repair urethral defects of 1 cm in male rabbits.

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair

INTRODUCTION

Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence.

METHODS

All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use, and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed.

RESULTS

We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, P = 0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, P < 0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, P < 0.001), and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, P = 0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, P = 0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, P < 0.001) remained highly associated with postoperative complications.

CONCLUSIONS

In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair.

Can regional anesthesia have an effect on surgical outcomes in patients undergoing distal hypospadia surgery?

BACKGROUND

Caudal and penile blocks are the most popular regional anesthetic techniques used in infants and children undergoing urological surgery. A recent report has suggested that penile venous pooling resulting from caudal blocks could affect surgical outcomes after hypospadias operations.

OBJECTIVE

The aim was to report our experience in patients with distal hypospadias undergoing repair with caudal versus penile block.

STUDY DESIGN

A retrospective clinical database was constructed for patients who underwent distal hypospadias repair by a single surgeon (M.P.B.) at our sponsoring institutions for the time period 2008-2013 (n = 192). Collected data included hypospadias classification (glanular, coronal, subcoronal), chordee status, perioperative anesthesia (caudal vs. penile), and assessment of postoperative complications (fistula and meatal stenosis).

RESULTS

Risk ratio (RR) analysis for all distal hypospadias cases revealed that there is a higher risk of developing complications in patients who underwent caudal anesthesia than in patients who underwent penile block RR for a complication was 3.70 (95% CI 1.05-13.03; p < 0.04) (Figure).

DISCUSSION

Similar to other papers in the literature, we found that patients who underwent caudal anesthesia had more complications than those who underwent penile block. The limitations of this study include not adjusting the results according to the severity of hypospadias.

CONCLUSION

The main goal of this study was accomplished by demonstrating that, in our series, caudal anesthesia is associated with a higher risk of fistula formation after undergoing distal hypospadias repair than penile block.

Cause and Effect versus Confounding-Is There a True Association between Caudal Blocks and Tubularized Incised Plate Repair Complications?

PURPOSE

We studied the impact of caudal block vs dorsal penile block on the rate of urethrocutaneous fistula and glans dehiscence in children who underwent hypospadias repair.

MATERIALS AND METHODS

We retrospectively reviewed the records of 849 consecutive patients who underwent tubularized incised plate repair between 2004 and 2015. A total of 331 cases with incomplete medical records, other techniques and redo repair were excluded. The preference for caudal block was based on anesthesiologist discretion. Age at surgery, meatal location, preoperative testosterone stimulation, type of regional anesthesia (caudal block vs dorsal penile block), degree of ventral curvature, surgeon expertise and complications (urethrocutaneous fistula/glans dehiscence) were captured. Univariate and multivariable analyses were done of risk factors for complications.

RESULTS

Median age at surgery was 18 months and median followup was 6 months. Of 518 patients 405 (78%) had distal and 113 (22%) had mid shaft/proximal defects. Complications developed in 37 cases (7%), including urethrocutaneous fistula in 21 (19 with a caudal block and 2 with a dorsal penile block) and glans dehiscence in 16 (13 with a caudal block and 3 with a dorsal penile block). On univariate analysis preoperative testosterone stimulation vs no preoperative testosterone stimulation (13.0% vs 6.2% of cases, p = 0.04), mid shaft/proximal vs distal defects (15.9% vs 4.7%, p <0.01) and caudal block (8.7% vs 3.3%, p = 0.03) were significantly associated with more complications. However, on multivariable analysis the associations of preoperative testosterone stimulation (OR 1.2, 95% CI 0.4-3.7) and caudal block (OR 2.4, 95% CI 0.9-6.4) with complications did not hold. Only the combination of meatal location/ventral curvature remained as an independent risk factor for urethrocutaneous fistula/glans dehiscence (OR 2.4, 95% CI 1.1-5.7, p = 0.04).

CONCLUSIONS

Our data indicate that hypospadias severity and not the type of regional anesthesia was the only risk factor significantly associated with postoperative complications. To confirm these findings and provide strong and definitive evidence on this topic a well powered, randomized, controlled trial is clearly required.

Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study

This study aimed to assess the association between caudal block and postoperative complications after tubularised incised plate urethroplasty. The medical records of 388 paediatric patients who underwent urethroplasty at a tertiary medical centre were analysed retrospectively. Among the 342 patients included, 216 patients received a caudal block and 72 (21.1%) patients suffered surgical complications. The number of patients having surgical complications was significantly greater among patients who received a caudal block than among patients who did not receive a caudal block (53 (24.5%) versus 19 (15.1%), respectively, p = 0.04). Based on multivariate logistic regression analysis, duration of surgery, caudal block and hypospadias types were independent risk factors for the surgical complications. Patients with caudal block had an odds ratio of 2.1 (95% CI, 1.14-3.81, p = 0.018) for the development of postoperative complications compared with patients without caudal block. This analysis demonstrates that caudal block is associated with surgical complications after tubularised incised plate urethroplasty.