Incidence of urethrocutaneous fistula following distal hypospadias repair with and without caudal epidural block: A randomized pilot study

Published:November 14, 2021DOI:https://doi.org/10.1016/j.jpurol.2021.11.006

      Summary

      Introduction

      Recent investigations have raised a doubt regarding the safety of Caudal epidural block (CEB) administered to children with distal hypospadias undergoing tubularised incised plate (TIP) urethroplasty. The primary objective of the study was to investigate whether there is any association between CEB and the occurrence of urethrocutaneous fistula (UCF) in the postoperative period.

      Methods

      Fifty ASA 1 and 2 children with distal hypospadias aged 0–8 years were randomly allocated to CEB group (GA with CEB, 0.2% ropivacaine 1 ml/kg; n = 25) and Non-CEB group (GA without CEB; n = 25). Penile measurements were taken before and 20 min after administration of CEB to assess penile engorgement. Intraoperative hemodynamics were recorded at 10 min intervals after induction of anaesthesia. Consumption of IV fentanyl intraoperatively and postoperatively in first 24 h was recorded in both the groups. Rescue analgesia was administered for a score >4 on FLACC scale. After surgery children were followed up monthly for first three months and then at 6-months and yearly in paediatric surgery OPD to assess for development of UCF.

      Results

      UCF was found to occur in only two children, one from each group on follow up, with an overall incidence of 4%. There was no difference in the incidence of UCF in the patients with and without CEB. A 26.8% increase in penile volume from baseline was recorded in CEB group (P = 0.000). The intraoperative heart rate and mean arterial pressure was significantly lower in the CEB group as compared to non CEB group at various time intervals. No additional intraoperative IV fentanyl supplementation was required in CEB group. Fentanyl consumption was significantly less in CEB group postoperatively in first 24 h (P = 0.000).

      Discussion

      Administration of CEB was not found to have any impact on UCF formation. No relationship between the increase in penile volume after CEB block and occurrence of UCF was noticed.

      Conclusion

      Despite increase in penile volume after CEB, there was no difference between the two groups as regards to the occurrence of post operative UCF. CEB is an effective analgesic modality and can be continued to be used till the results of well powered prospective randomised trials with long follow up are reported.

      Keywords

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic and Personal
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to Journal of Pediatric Urology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Ayob F.
        • Arnold R.
        Do CEBs cause complications following hypospadias surgery in children?.
        Anaesthesia. 2016; 71: 759-763
        • Orkiszewski M.
        A standardized classification of hypospadias.
        J Pediatr Urol. 2012 Aug; 8: 410-414
        • Bhat A.
        • Mandal A.K.
        Acute postoperative complications of hypospadias repair.
        Indian J Urol. 2008; 24: 241-248
        • Wilkinson D.J.
        • Farrelly P.
        • Kenny S.E.
        Outcomes in distal hypospadias: a systematic review of the Mathieu and tubularized incised plate repairs.
        J Pediatr Urol. 2012 Jun; 8: 307-312
        • Woodhouse C.R.
        • Christie D.
        Nonsurgical factors in the success of hypospadias repair.
        BJU Int. 2005; 96: 22-27
        • Mondaini N.
        • Ponchietti R.
        • Bonafè M.
        • Biscioni S.
        • Di Loro F.
        • Agostini P.
        • et al.
        Hypospadias: incidence and effects on psychosexual development as evaluated with the Minnesota Multiphasic Personality Inventory test in a sample of 11,649 young Italian men.
        Urol Int. 2002; 68: 81-85
        • Cimador M.
        • Vallasciani S.
        • Manzoni G.
        • Rigamonti W.
        • De Grazia E.
        • Castagnetti M.
        Failed hypospadias in paediatric children.
        Nat Rev Urol. 2013; 10: 657-666
        • Morrison K.
        • Herbst K.
        • Corbett S.
        • Herndon C.D.
        Pain management practice patterns for common pediatric urology procedures.
        Urology. 2014; 83: 206-210
        • Uguralp S.
        • Mutus M.
        • Koroglu A.
        • Gurbuz N.
        • Koltuksuz U.
        • Demircan M.
        Regional anaesthesia is a good alternative to general anaesthesia in pediatric surgery: experience in 1,554 children.
        J Pediatr Surg. 2002; 37: 610-613
        • Kundra P.
        • Yuvaraj K.
        • Agrawal K.
        • Krishnappa S.
        • Kumar L.T.
        Surgical outcome in children undergoing hypospadias repair under caudal epidural vs. penile block.
        Paediatr Anaesth. 2012; 22: 707-712
        • Braga L.H.
        • Jegatheeswaran K.
        • McGrath M.
        • Easterbrook B.
        • Rickard M.
        • DeMaria J.
        • et al.
        Cause and effect versus confounding-is there a true association between caudal blocks and tubularized incised plate repair complications?.
        J Urol. 2017; 197: 845-851
        • Zaidi R.H.
        • Casa1nova N.F.
        • Haydar B.
        • Voepel-Lewis T.
        • Wan J.H.
        Urethrocutaneous fistula following hypospadias repair: regional anaesthesia and other factors.
        Paediatr Anaesth. 2015; 25: 1144-1150
        • Kreysing L.
        • Höhne C.
        A retrospective evaluation of fistula formation in children undergoing hypospadias repair and caudal anaesthesia.
        Paediatr Anaesth. 2016; 26: 329-330
        • Splinter
        • Wm
        • Kim J.
        • Kim A.M.
        • Harrison M.A.
        • et al.
        Effect of anaesthesia for hypospadias repair on perioperative complications.
        Paediatr Anaesth. 2019; 29: 760-767
        • Kim M.H.
        • Im Y.J.
        • Kil H.K.
        • Han S.W.
        • Joe Y.E.
        • Lee J.H.
        Impact of CEB on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study.
        Anaesthesia. 2016; 71: 773-778
        • Taicher B.M.
        • Routh J.C.
        • Eck J.B.
        • Ross S.S.
        • Wiener J.S.
        • Ross A.K.
        The association between caudal anaesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair.
        Paediatr Anaesth. 2017; 27: 688-694
        • Saavedra-Belaunde J.A.
        • Soto-Aviles O.
        • Jorge J.
        • Escudero K.
        • Vazquez-Cruz M.
        • Perez-Brayfield M.
        Can regional anaesthesia have an effect on surgical outcomes in children undergoing hypospadias surgery?.
        J Pediatr Urol. 2017; 13 (45.e1-4)
        • Zhu C.
        • Wei R.
        • Tong Y.
        • Liu J.
        • Song Z.
        • Zhang S.
        Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis.
        Reg Anesth Pain Med. 2019 Feb; 44: 259-267
        • Wood H.M.
        • Kay R.
        • Angermeier K.W.
        • Ross J.H.
        Timing of the presentation of UCFs after hypospadias repair in pediatric patients.
        J Urol. 2008; 180: 1753-1756
        • Snodgrass W.
        • Villanueva C.
        • Bush N.C.
        Duration of follow-up to diagnose hypospadias urethroplasty complications.
        J Pediatr Urol. 2014; 10: 208-211
        • Shankar K.R.
        • Losty P.D.
        • Hopper M.
        • Wong L.
        • Rickwood A.M.
        Outcome of hypospadias fistula repair.
        BJU Int. 2002 Jan; 89: 103-105
        • Barbagli G.
        • De Angelis M.
        • Palminteri E.
        • Lazzeri M.
        Failed hypospadias repair presenting in adults.
        Eur Urol. 2006 May; 49 (discussion 895): 887-894
        • Marrocco G.
        • Vallasciani S.
        • Fiocca G.
        • Calisti A.
        Hypospadias surgery: a 10-year review.
        Pediatr Surg Int. 2004; 20: 200-203
        • Goel P.
        • Jain S.
        • Bajpai M.
        • Khanna P.
        • Jain V.
        • Yadav D.K.
        Does caudal analgesia increase the rates of UCF formation after hypospadias repair? Systematic review and meta-analysis.
        Indian J Urol. 2019; 35 (Shankar KR, Losty PD, Hopper M, Wong L, Rickwood AM. Outcome of hypospadias fistula repair. BJU Int. 2002 Jan;89(1):103-229): 222-229
        • Kaplanian S.
        • Chambers N.A.
        • Forsyth I.
        Caudal anaesthesia as a treatment for penile ischaemia following circumcision.
        Anaesthesia. 2007; 62: 741-743
        • Alizadeh F.
        • Heydari S.M.
        • Nejadgashti R.
        Effectiveness of CEB on interaoperative blood loss during hypospadias repair: a randomized clinical trial.
        J Pediatr Urol. 2018; 14 (e1-420.e5)
        • Naja Z.
        • Al-Tannir M.A.
        • Faysal W.
        • Daoud N.
        • Ziade F.
        • El-Rajab M.
        A comparison of pudendal block vs. dorsal penile nerve block for circumcision in children: a randomised controlled trial.
        Anaesthesia. 2011; 66: 802-807
        • Ngoo A.
        • Borzi P.
        • McBride C.A.
        • Patel B.
        Penile nerve block predicts higher revision surgery rate following distal hypospadias repair when compared with CEB: a consecutive cohort study.
        J Pediatr Urol. 2020; 16 (439.e1-439.e6)
        • Merella F.
        • Canchi-Murali N.
        • Mossetti V.
        General principles of regional anaesthesia in children.
        BJA Educ. 2019 Oct; 19: 342-348