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

Braga, Luis H.; Jegatheeswaran, Kizanee; McGrath, M. A.; Easterbrook, Bethany; Rickard, Mandy; DeMaria, Jorge; Lorenzo, Armando J.

doi:10.1016/j.juro.2016.08.110

Cited by 34 publications

(34 citation statements)

References 14 publications

Supporting

Mentioning

Contrasting

Order By: Relevance

“…Although patient selection for caudal block was based on anesthesiologist discretion, a higher proportion of children with mid-shaft/proximal hypospadias received a caudal block compared with those with distal defects 10. To adjust for this imbalance between the groups and to eliminate potential selection bias involving caudal block indication, we performed subgroup analysis including only patients with distal hypospadias 5 9 10 23 24.…”

Section: Resultsmentioning

confidence: 99%

“…On the other hand, non-randomized assignment to intervention may occur in observational studies. Which kind of anesthesia (caudal block or DNPB) the patient received was mainly determined by anesthesiologist discretion and patients with severe hypospadias were more likely to receive caudal block and not DNPB 10. This imbalance might introduce bias in measurement classification of interventions and selection bias.…”

Section: Resultsmentioning

confidence: 99%

See 1 more Smart Citation

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

Zhu

Rong

Tong

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

View full text Add to dashboard Cite

Background and objectivesis 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.MethodsWe 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.ResultsIn 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.ConclusionsIn RCTs, only limited data showed peripheral nerve blocks providing better analgesic qua...

show abstract

Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

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

Zhu

Rong

Tong

et al. 2019

Regional Anesthesia &Amp; Pain Medicine

View full text Add to dashboard Cite

show abstract

“…Similar to what they report, our surgeon routinely injected lidocaine with epinephrine in the glans during all repairs except the most minimal glanular cases including those with and without caudal anesthetics. Finally, Braga et al (11) found a statistically significant association between fistula development or glans dehiscence and pre-operative use of testosterone, proximal hypospadias, and use of caudal block on univariate analysis; however, the association was only significant for proximal hypospadias on multivariate analysis. Therefore, they concluded, as did Zaidi et al ,(12) that the association between complications and caudal block was only a confounder and that the severity of the hypospadias was the only predictor of complications.…”

Section: Discussionmentioning

confidence: 97%

“…Conversely, such association was not confirmed by two other studies. (11, 12) There remains a need to answer this important question regarding any association of caudal anesthetic technique and postoperative surgical complications.…”

Section: Introductionmentioning

confidence: 99%

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

Taicher

Routh

Eck

et al. 2017

Pediatric Anesthesia

View full text Add to dashboard Cite

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.

show abstract

“…There is ongoing controversy whether caudal blocks lead to a higher incidence of urethral fistulas, although the evidence is of poor quality and needs confirmation. 28 …”

Section: Operative Principlesmentioning

confidence: 99%

Current hypospadias management: Diagnosis, surgical management, and long-term patient-centred outcomes

Keays

Davé

2017

CUAJ

104

View full text Add to dashboard Cite

show abstract

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

Cited by 34 publications

References 14 publications

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

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

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

Current hypospadias management: Diagnosis, surgical management, and long-term patient-centred outcomes

Contact Info

Product

Resources

About