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Vessel-sparing Excision and Primary Anastomosis
Published on: January 7, 2019
Cause and Effect versus Confounding-Is There a True Association between Caudal Blocks and Tubularized Incised Plate
Luis H Braga1, Kizanee Jegatheeswaran2, Melissa McGrath2
1Clinical Urology Research Enterprise Program, McMaster Children's Hospital, Hamilton, Ontario, Canada.
Insights
This study found that hypospadias severity, not the type of regional anesthesia used, is the primary risk factor for postoperative complications in children. Further randomized trials are needed to confirm these findings on urethrocutaneous fistula and glans dehiscence rates.
Area of Science:
- Pediatric Urology
- Surgical Outcomes
- Anesthesiology
Background:
- Hypospadias repair is a common pediatric urological procedure.
- Postoperative complications such as urethrocutaneous fistula and glans dehiscence can impact outcomes.
- Regional anesthesia techniques, including caudal block and dorsal penile block, are employed to manage pain during these repairs.
Purpose of the Study:
- To investigate the impact of caudal block versus dorsal penile block on the incidence of urethrocutaneous fistula and glans dehiscence in pediatric hypospadias repair.
- To identify risk factors associated with postoperative complications following hypospadias surgery.
Main Methods:
- Retrospective review of 849 pediatric patients undergoing tubularized incised plate repair between 2004 and 2015.
- Exclusion of 331 cases with incomplete records, alternative techniques, or previous repairs.
- Analysis of patient demographics, surgical details, anesthesia type, and postoperative complications (fistula, dehiscence).
Main Results:
- Complications occurred in 7% of 518 analyzed patients.
- Univariate analysis suggested associations between preoperative testosterone stimulation, mid-shaft/proximal defects, and caudal block with increased complications.
- Multivariable analysis revealed that only meatal location and ventral curvature remained independent risk factors for complications.
Conclusions:
- Hypospadias severity, indicated by meatal location and ventral curvature, is the significant risk factor for postoperative complications.
- The type of regional anesthesia (caudal block vs. dorsal penile block) was not found to be an independent risk factor.
- A well-powered, randomized controlled trial is recommended to definitively establish the role of anesthesia in hypospadias repair outcomes.
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.
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