Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors

Zaidi, Raza H.; Casanova, Nathalie; Haydar, Bishr; Voepel‐Lewis, Terri; Wan, Julian

doi:10.1111/pan.12719

Cited by 49 publications

(48 citation statements)

References 26 publications

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“…However, no association between fistula formation and use of caudal anesthesia was noted; instead, this group found that the use of subcutaneous epinephrine was instead associated with an increased risk of urethrocutaneous fistula formation. (12) Because this latter datum was not captured by our surgical database in any consistent or meaningful way, we are unable to comment on whether it may have played a role in our findings (e.g., if subcutaneous epinephrine was used more consistently among patients who also happened to receive caudal anesthesia). 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.…”

Section: Discussionmentioning

confidence: 93%

“…(9) found complications in 25% of their 342 patients having tubularized incised plate urethroplasty hypospadias repair undergoing a caudal block compared to 15% of those not receiving a caudal block. In contrast, Zaidi et al (12) investigated the incidence of urethrocutaneous fistula formation and its association with caudal anesthesia and found that the location of the urethral opening (proximal > mid > distal shaft) was strongly associated with fistula development. However, no association between fistula formation and use of caudal anesthesia was noted; instead, this group found that the use of subcutaneous epinephrine was instead associated with an increased risk of urethrocutaneous fistula formation.…”

Section: Discussionmentioning

confidence: 98%

“…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%

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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

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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.

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Section: Discussionmentioning

confidence: 93%

Section: Discussionmentioning

confidence: 98%

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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

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“…To minimize confounding biases, most studies performed multivariate logistic regression 5 9 10 24. Furthermore, four studies performed subgroup analysis,5 9 10 24 and one study performed matching groups 9. Nevertheless, a higher complication rate appeared in the early time period compared with that of the later period,12 but the trials did not provide relevant information regarding caudal block distributed by time.…”

Section: Resultsmentioning

confidence: 99%

“…However, data were reviewed from institutional billing database and records by trained and independent investigators. The blinding and rigorous reviewing process might decrease selection bias 9. Additionally, surgeries were performed by one surgeon,5 11 23–25 which removes a potential confounding variable of multiple surgeons and potential selection bias 16.…”

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

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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...

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Variables in Hypospadias Repair

Bhat

2022

Hypospadiology

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Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors

Cited by 49 publications

References 26 publications

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

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

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

Variables in Hypospadias Repair

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