Association of Analgesic Block With the Incidence of Complications Following Hypospadias Surgery; A Meta-Analysis

doi:10.1016/j.urology.2022.03.002

Urology

Volume 166, August 2022, Pages 11-17

https://doi.org/10.1016/j.urology.2022.03.002 Get rights and content

Abstract

To examine the association between type of analgesic block and incidence of complications following primary hypospadias correction. Data sources included MEDLINE, Embase, Web of Science and the Cochrane Library, inception-01/2021. Randomized clinical trials, cohort and case control studies reporting original data for patients <18 years of age undergoing primary hypospadias correction with either a penile or caudal block for which outcomes (urethrocutaneous fistula or glans dehiscence) were reported. Two researchers independently extracted data and assessed quality for inclusion. The primary outcome was the incidence of complication within six-months postoperatively based on block performed. Ten studies (3201 patients; range: 54-983) were included. Six studies (cumulative weight 28.6%) favored penile block while 4 studies (cumulative weight 71.4%) favored caudal block. Compared to the reference group of penile blocks, caudal blocks had no significant association with development of complications following primary hypospadias correction (relative risk 1.11, 95% CI (0.88, 1.41); P = .38). When adjusting for meatal location (distal vs proximal) there was no significant association with development of fistulae or glanular dehiscence following primary hypospadias correction with caudal blocks in comparison to the reference group, penile blocks for distal, (relative risk 1.46, 95%CI (0.98, 2.17); P = .065) and proximal (relative risk 0.95, 95% CI (0.58, 1.54); P = .823). The type of analgesic block is not associated with the risk of developing complications following primary hypospadias correction in children. Caudal block should be considered for these urological interventions.

Section snippets

Search Strategies

The protocol of this review was registered prospectively with the PROSPERO registry (#CRD42020220327). The study was preformed according to the Cochrane collaboration recommendations and complies with the Preferred Reporting Items for Systematic Reviews and Meta Analyses statement (PRISMA). The PROSPERO registry was updated on June 13, 2021 to indicate completion of the analysis as well as to denote that a minimum of 6 months postoperative follow-up was required for inclusion (accidently

RESULTS

The database search yielded 350 records (Fig. 1). After removal of duplicated records, 178 studies were screened from which 28 full text articles were assessed for eligibility. Of those 28 studies, 17 studies met our qualitative criteria for examination and 10 studies within this group met predetermined criteria for quantitative examination and meta-analysis Figure 1, PRISMA flow diagram, details the study selection process (Fig. 1).

A total of 3201 patients from 10 studies met study inclusion

DISCUSSION

Debate as to the impact of caudal blocks on outcomes following hypospadias correction in children exists. Some physicians have speculated that caudal blocks cause penile engorgement and the resulting tissue edema delays wound healing. However, a definitive biologic mechanism for why caudal blocks may be associated with worse outcomes has never been demonstrated.⁵^,²² While the previous meta-analysis published by Tanesco et al. in 2019 identified an increase in postsurgical complications for

REGISTRY

PROSPERO #CRD42020220327

AUTHORS CONTRIBUTION

Dr. Adler conceptualized and designed the study, drafted the initial manuscript, and reviewed and revised the manuscript and was responsible for meta-analysis registry. Dr. Bhatia designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. Chandrakantan designed the study, drafted the initial manuscript, and reviewed and revised the manuscript. Dr. Nathanson conducted statistical analysis for the manuscript, and reviewed and revised the manuscript. Ms.

References (28)

LH Braga et al.
Cause and Effect versus Confounding-Is there a true association between caudal blocks and tubularized incised plate repair complications?
J Urol
(2017)
H Buson et al.
Distal hypospadias repair without stents: is it better?
J Urol
(1994)
S Hakim et al.
Outcome analysis of the modified Mathieu hypospadias repair: comparison of stented and unstented repairs
J Urol
(1996)
R. Rabinowitz
Outpatient catheterless modified Mathieu hypospadias repair
J Urol
(1987)
AB Retik et al.
Management of severe hypospadias with a 2-stage repair
J Urol
(1994)
LJ Paulozzi et al.
Hypospadias trends in two US surveillance systems
Pediatrics
(1997)
S Suresh et al.
Are caudal blocks for pain control safe in children? an analysis of 18,650 caudal blocks from the Pediatric Regional Anesthesia Network (PRAN) database
Anesth Analg
(2015)
AC Adler et al.
Effect of caudal vs. penile block on the incidence of hypospadias complications following primary repairs: a retrospective cohort study
J Urol
(2021)
PP Tanseco et al.
Postoperative complications of hypospadias repair in patients receiving caudal block vs. non-caudal anesthesia: a meta-analysis
Can Urol Assoc J
(2019)
B. Haydar
Editorial comment
J Urol
(2021)

T. Khoury

Editorial comment

J Urol

(2021)

JC. Routh

Caudal blocks and hypospadias repair complications-much ado about nothing or the real deal?

J Urol

(2021)

Methods C. RoB 2: A revised Cochrane risk-of-bias tool for randomized trials....

JA Sterne et al.

ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions

Bmj

(2016)

Cited by (11)

Modified PATIO technique for urethrocutaneous fistula after hypospadias repair: Experience from a tertiary referral hospital
2024, Journal of Pediatric Urology
Urethrocutaneous fistula (UCF) is a common complication after hypospadias repair with an incidence of 5–10%. Several techniques are described for its repair: small UCFs are frequently corrected by isolation, excision, and closure with apposition of a protective second layer. In 2008 Malone described the PATIO technique: the fistula tract is turned inside out in the urethral lumen preventing contact with passing urine without direct urethral sutures.
Aim of our study is to present our outcomes using a modified version of the PATIO technique, with a more reproducible isolation of the tract and without its fixation at the urethral meatus.
We retrospectively reviewed all cases of UCFs corrected with a modified PATIO technique at our center between 2016 and 2020. Data collected from electronical clinical notes were age at UCF closure, location of UCF, presence of meatal stenosis and clinical outcomes. Data are presented as median and IQR.
In the study period we performed 425 urethroplasties for distal and mid penile hypospadias. The incidence of UCFs was 7% (30/425) and 25 patients underwent UCF correction with modified PATIO. Median age at repair was 4.5 years (IQR: 2.5–6.2). At a median follow-up of 3 years (IQR: 2–4) recurrence was observed in 5 cases out of 24 with one patient who was lost at follow-up (20.8%). One case was corrected successfully with re-do modified PATIO technique, while 4 are awaiting repair. One cases was lost at follow-up. UFC-recurrence was homogeneously distributed along the study period.
Risk factors for UCF recurrence are mostly the type of hypospadias, neo-urethral length, and quality of the urethral plate. Among the many existing techniques, we propose a modified version of Malone's PATIO repair. We believe that the use of four stay-suture to isolate the fistula allows a well-defined dissection of the tract along its surface, compared to the use of a single stay-suture. In our experience, there is no need to keep and fix the traction on the fistula tract to the urethral meatus, probably reflecting the efficacy of the fistula closure during the introflection, which is then maintained without traction. Limitations to our study include the retrospective nature of the review, the small sample size of the cohort and the absence of control groups.
Our results appear consistent with literature regarding the efficacy of PATIO principles in treating UCF. Modified PATIO seem to be particularly reproducible, showing encouraging results.
Fragility index of meta-analyses and randomized-controlled trials on the efficacy of caudal block for hypospadias: Is the glass half-full or half-empty?
2023, Journal of Pediatric Urology
Impact of caudal block on revision rates after hypospadias repair: Multi-institution review
2023, Journal of Pediatric Urology
There is controversy surrounding the association between caudal block and complication rates after hypospadias repair. Conflicting results have been reported mostly from single-center, low volume studies and those that did not include relevant variables.
We hypothesized that caudal block is not associated with increased rates of reoperation after primary repair and is associated with more complex hypospadias surgery.
The Clinical Practice Solutions Center database was queried to identify patients who received a primary hypospadias repair between 2009 and 2010. Primary hypospadias repair was further categorized as meatal advancement and glanduloplasty, distal, one-stage proximal, or one-stage perineal repair. Anesthesia coding was evaluated to identify those who received a caudal block. Any revision surgery was captured between 2009 and 2019 and the types of revision surgeries were identified. Variables such as caudal block, age, insurance type, surgeon volume, and surgeon years in practice were analyzed with mixed effects multiple logistic regression models.
The dataset query identified 3343 pediatric males who had primary hypospadias repair. The procedures were performed by 50 surgeons at 27 hospitals. Primary surgeries included meatal advancement and glanduloplasty (23%), distal (69%), proximal (6.9%), and perineal repairs (1%). Caudal block was administered to 42% of patients. Utilization of caudal block was not associated with type of primary surgery (p = 0.21). Adjusting for all other variables, increased patient age was associated with decreased usage of caudal block (p < 0.001). Analysis did not demonstrate a statistically significant association between utilization of caudal block with rates of revision surgery.
This large, multi-institution study demonstrates that the use of caudal block was not associated with more complex hypospadias surgery nor statistically significantly associated with increased rates of revision surgery after primary hypospadias repair.
Pendulum swings again in favour of caudal block for hypospadias
2023, Journal of Pediatric Urology
Urethrocutaneous fistula and glans dehiscence formation of hypospadias surgery in patients receiving caudal block vs. non-caudal block: A meta-analysis
2023, Journal of Pediatric Urology
This meta-analysis aimed to evaluate the difference in postoperative complications as urethrocutaneous fistula or glans dehiscence, in children undergoing primary hypospadias repair with caudal block (CB) versus non-caudal block (NCB).
Data were obtained from MEDLINE, Embase, Web of Science, and the Cochrane Library. Comparative studies of CB versus NCB were identified, with reports of complications published or presented until October 2022. Subgroup analyses were performed based on study type, meatal location (distal only), type of NCB, surgeon and technique, and concentration and dose of anesthetics.
Compared to the reference group of NCB, CB was not significantly associated with the development of complications following primary hypospadias repair (OR 1.40, 95 % CI 0.88–2.23). After adjusting for confounding factors, such as type of study(OR 1.51, 95%CI: 0.29–7.91), type of NCB[PB (OR 1.82, 95 % CI: 0.87–3.84), GA (OR 1.26, 95 % CI: 0.39–4.04)], meatal location (distal only) (OR 1.22, 95 % CI: 0.61–2.43), surgeon and technique (OR 1.37, 95 % CI: 0.59–3.14) and concentration and dose of anesthetics(OR 2.74, 95 % CI: 0.82–9.20), subgroup analyses revealed no significant association between CB and NCB (P > 0.05).
Previous studies have found a correlation between CB and increased incidence of postoperative complications (urethrocutaneous fistula or glans dehiscence) of hypospadias, but different literature have suggested that surgical technique, surgical duration and the severity of hypospadias, rather than CB, are closely related to the occurrence of complications. In order to reduce confounding factors, subgroup analyses were conducted. The results showed that no correlation could be found in postoperative complications and CB.
This meta-analysis compared the incidence of urethrocutaneous fistula or glans dehiscence in the CB and NCB groups for primary hypospadias repair in children, indicating that no clear correlation could be found in postoperative complications and CB. Subgroup analyses on study type, type of NCB, meatal location (distal only), surgeon and technique, and regional anesthetic concentration and dose supported this conclusion.
Efficacy of adjuvant dexmedetomidine on penile block for pediatric hypospadias repair
2023, Journal of Pediatric Urology
The management of postoperative pain, particularly in younger children, presents a challenge due to their limited ability to articulate the intensity of pain, lower pain threshold, and restricted availability of approved analgesics for pediatric use. Peripheral nerve blocks may be favored over neuraxial blocks because they allow quicker mobilization after surgery.
The present study aims to investigate the potential impact of adding dexmedetomidine to a local anesthetic (bupivacaine) on the analgesic efficacy in dorsal penile nerve block in hypospadias repair surgery.
In this prospective double-blinded clinical trial, 50 children aged between 6 months and 6 years old undergoing hypospadias repair surgery participated. Analgesia was administered through a dorsal penile nerve block (DPNB) at the end of surgery. Participants were divided into two groups; one received bupivacaine alone, and the other received dexmedetomidine and bupivacaine in DPNB. Pain and sedation levels were assessed with FLACC score and MOAA/S score, respectively, at 0,1,2 and 4 h after surgery. Vital signs and adverse effects were also recorded, including hemodynamic changes, nausea, and vomiting.
There was no statistically significant difference in demographic variables. As illustrated in Figure, the median of FLACC score in group BD was significantly lower compared to group B at every measured time point. MOAA/S score was significantly lower in group BD than in group B (p < 0.001), indicating a higher sedation level. None of the participants in either group experienced any adverse effect except for vomiting, which was not statistically significant (8 % in group B vs. 4 % in group BD, p > 0.999).
Several studies have documented the supplementary analgesic properties of dexmedetomidine when used in conjunction with local anesthetic during various surgical procedures and nerve blocks. The present study provides evidence for the additional analgesic efficacy of dexmedetomidine and bupivacaine in the context of dorsal penile nerve block during hypospadias repair surgery while not yielding any significant adverse outcomes. Although the patients in our study were monitored for 4 h in the postanesthesia care unit (PACU), conducting a more comprehensive assessment of patients is advisable.
The findings of our study indicate that incorporating dexmedetomidine alongside bupivacaine in dorsal penile nerve block during hypospadias repair surgery may lead to enhanced management of postoperative pain. The lack of adverse effects implies it may be a potentially safe supplementary pain reliever for surgical procedures.

View all citing articles on Scopus

: Drs Adler and Bhatia have contributed equally to constitute first authorship.

: Disclosure: Dr. Austin is a consultant to Allergan and Urovant. The remaining authors have no conflicts of interest to disclose.

: Funding Support: No funding was secured for this study.

View full text

ReviewAssociation of Analgesic Block With the Incidence of Complications Following Hypospadias Surgery; A Meta-Analysis

Abstract

Section snippets

Search Strategies

RESULTS

DISCUSSION

REGISTRY

AUTHORS CONTRIBUTION

J Urol

J Urol

J Urol

J Urol

J Urol

Hypospadias trends in two US surveillance systems

Pediatrics

Are caudal blocks for pain control safe in children? an analysis of 18,650 caudal blocks from the Pediatric Regional Anesthesia Network (PRAN) database

Anesth Analg

Effect of caudal vs. penile block on the incidence of hypospadias complications following primary repairs: a retrospective cohort study

J Urol

Postoperative complications of hypospadias repair in patients receiving caudal block vs. non-caudal anesthesia: a meta-analysis

Can Urol Assoc J

Editorial comment

J Urol

Editorial comment

J Urol

Caudal blocks and hypospadias repair complications-much ado about nothing or the real deal?

J Urol

ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions

Bmj

Review
Association of Analgesic Block With the Incidence of Complications Following Hypospadias Surgery; A Meta-Analysis