Conclusion: Penile block provided better analgesia when compared with caudal epidural in children undergoing primary hypospadias repair. Postoperative urethral fistula formation was more likely in children who received caudal epidural.
Editorial CommentThis is a prospective randomized controlled trial comparing penile block with a caudal block for children undergoing hypospadias repair. They had 27 children in each group. Their patient population was older than most contemporary series with ages ranging from 4-12 years. Penile measurements were taken before and 10 minutes after the block in both groups. Breakthrough fentanyl was given for patients with increase in mean arterial pressure (MAP) or heart rate greater than 15% from baseline. Visual analogue scores were measured at various intervals over the course of 4 days. The authors found that pain scores were significantly worse in the group receiving the caudal block. In addition, changes in MAP and heart rate were significantly higher in the caudal group. This resulted in increased use of narcotics for the caudal block group. Five patients developed urethrocutaneous fistula. All of these patients were in the caudal group. The authors speculated that this may be due to the increase in penile volume that was seen in the caudal group but not observed in the penile block group.Both penile and caudal blocks are used routinely for hypospadias repair. There is very limited data comparing the two in a prospective fashion as these authors have done. The decision of which type of regional anesthesia to perform is often based on the preference of the surgeon or anesthesiologist involved and over time a particular type of block simply becomes part of the culture of each individual institution. The authors only included patients with midshaft to distal hypospadias. Their fistula rate of nearly 20% seems high for a primary repair in such patients. It is interesting that all of these fistulas occurred in the caudal group. More prospective studies with greater numbers of patients would be helpful to improve our care for a common procedure.
Dr. M. Chad Wallis Division of Pediatric UrologyUniversity of Utah Salt Lake City, Utah, USA E-mail: chad.wallis@hsc.utah.edu Effects of botulinum toxin type a in the bladder wall of children with neurogenic bladder dysfunction: a comparison of histological features before and after injections Pascali MP, Mosiello G, Boldrini R, Salsano ML, Castelli E, De Gennaro M Department of Nephro-Urology, Bambino Gesù Pediatric and Research Hospital, Piazza S. Onofrio 4, Rome, Italy J Urol. 2011; 185(6 Suppl): 2552-7 Purpose: Botulinum toxin type A has gained popularity in urology. Most reported studies have been in adults at urology centers and most have addressed long-term safety. Since botulinum toxin type A treatment for neurogenic bladder dysfunction requires repeat injections, verifying that such treatment does not induce fibrosis in children seems essential.
children and adolescents (3-18years) suffering from severe sphincteric incompetence (exstrophy-epispadias 33, neuropathic bladder 44, bilateral ectopic ureters 5, miscellaneous 4) have been treated and followed for a minimum of 18months up to 12 years (median 60 months). A third had had a previous failed bladder neck procedure. Preoperative evaluation consisted in medical history and questionnaire about incontinence, urine culture, urinary tract ultrasound and videourodynamics. This evaluation was repeated at six months and one year after treatment and then on a yearly basis,except for videourodynamics performed only when necessary for further management. 25 patients had two and 13 three treatment sessions. Mean injected volume was 4,6 ml per session. At each evaluation, the patient was classified as cured (dryness interval of four hours ), significantly improved (minimal incontinence requiring no more than one pad per day; no further treatment required) and treatment failure when no significant improvement was observed.RESULTS: 32 (37,2%) patient are dry, 13/86 (15,1%) are significantly improved, and 41/86 (47,7%) patients had treatment failure. After 18 months of FU 2 male patients became dry at puberty 2 Female patients became incontinent again. All the other patients remained perfectly stable.CONCLUSIONS: Endoscopic treatment of urinary sphincter insufficiency with Deflux® is effective in around 50% of cases after 18months; our study with the largest reported cohort and the longest FU confirms that this result is durable up to 12 years thereafter.
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