Surgical outcome in children undergoing hypospadias repair under caudal epidural vs penile block

Abstract

Urological Survey 799 Editorial CommentThis study though based on a cross-sectional survey with small patient numbers restraining its power, adds to the limited literature concerning clinically relevant fatigue (CRF) in men with biochemically controlled prostate cancer on long term GnRH-based ADT.The main findings were as follows: -CRF prevalence in the sample was 43% (95% CI 35% to 50%) and the difference in scores between those with and without CRF far exceeded the 20 points described as a 'large' clinically significant; -CRF was associated with moderate/severe pain, depression, anxiety, concurrent co-morbidities and moderate/severe urinary symptoms but the only independent associations of CRF were depression and pain.Fatigue may be attenuated optimizing depression and pain treatments. Methods: Fifty-four ASA I and II children were randomly allocated to group P (penile block, 0.25% bupivacaine, 0.5 mg·kg (-1); n = 27) and group C (caudal epidural, 0.25% bupivacaine, 0.5 mL·kg (-1); n = 27), respectively. Quality of analgesia was assessed by visual analog scale (VAS) score recorded at 0, 0.5, 3, 6, 12, 24 h, and once a day for the next 4 days. Duration of analgesia was calculated from the institution of block to the first analgesic demand by child or VAS > 5. Total morphine consumption in the first 48 h and oral paracetamol consumption till 5th day were recorded. Children were regularly followed up in their respective outpatient clinic for early or late complications. Dr. Leonardo Oliveira ReisResults: In group P, lower mean VAS scores were seen from 0.5 h after surgery till day 3 and analgesia lasted for significantly longer duration (82 min) when compared with caudal epidural, P < 0.001. Incidence of urethral fistula formation after primary hypospadias repair was 19.2%, and all had received caudal epidural. An increase of 27% in penile volume from baseline value was observed 10 min after caudal epidural placement, P < 0.05.

Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors

“…In addition, the use of subcutaneous epinephrine was also identified as a risk factor for fistula formation. Alternatively, we found no association between the caudal analgesia use and the urethrocutaneous fistula formation, in contrast to Kundra's study . Their proposed mechanism of action, being that caudal analgesia promotes penile edema, has not been previously described.…”

“…In addition, recent data from Kundra et al . in 2012 demonstrated an association between use of caudal epidural blocks and fistula formation. This finding was attributed to penile engorgement, a known consequence of caudal epidural blocks.…”

Hypospadias repair and caudal analgesia: biases and myths hinder meaningful meta-analysis

“…During the preparation of our manuscript on caudal analgesia in hypospadias patients, included in their review, we extensively searched the literature to find evidence of epidural anesthesia or analgesia causing edema in humans and found none 2 3. Dr Kundra postulated that penile engorgement due to the sympathectomy caused by caudal anesthesia led to edema,4 but this is a normal physiological process that is not associated with edema formation.…”

Letter to the editor for the article titled ‘Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis’

“…As this review is specific and includes so few RCTs, it is critical to not miss any data of included RCTs. Kundra et al also reported the pain scores 24 hours after the surgery by an error bar graph, but it not be included in this meta-analysis 5. To avoid missing some critical data, we recommend that authors use graphical data extraction software to incorporate data.…”