On-line version ISSN 1677-6119
Int. braz j urol. vol.37 no.6 Rio de Janeiro Nov./Dec. 2011
Surgical outcome in children undergoing hypospadias repair under caudal epidural vs penile block
Kundra P; Yuvaraj K; Agrawal K; Krishnappa S; Kumar LT
Department of Anaesthesiology & Critical Care, Jawaharlal Institute of Postgraduate Medical Education and Research (J.I.P.M.E.R), Pondicherry, India Department of Plastic Surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (J.I.P.M.E.R), Pondicherry, India Department of Paediatric surgery, Jawaharlal Institute of Postgraduate Medical Education and Research (J.I.P.M.E.R), Pondicherry, India
Paediatr Anaesth. 2011; 29. [Epub ahead of print]
AIM AND OBJECTIVE: To evaluate the effect of penile block vs caudal epidural on the quality of analgesia and surgical outcome following hypospadias repair.
BACKGROUND: Intraoperative penile engorgement because of caudal epidural may result in tension on surgical sutures and alter surgical outcome.
METHODS: Fifty-four ASA I and II children were randomly allocated to group P (penile block, 0.25% bupivacaine, 0.5 mg·kg (-1); n = 27) and group C (caudal epidural, 0.25% bupivacaine, 0.5 mL·kg (-1); n = 27), respectively. Quality of analgesia was assessed by visual analog scale (VAS) score recorded at 0, 0.5, 3, 6, 12, 24 h, and once a day for the next 4 days. Duration of analgesia was calculated from the institution of block to the first analgesic demand by child or VAS > 5. Total morphine consumption in the first 48 h and oral paracetamol consumption till 5th day were recorded. Children were regularly followed up in their respective outpatient clinic for early or late complications.
RESULTS: In group P, lower mean VAS scores were seen from 0.5 h after surgery till day 3 and analgesia lasted for significantly longer duration (82 min) when compared with caudal epidural, P < 0.001. Incidence of urethral fistula formation after primary hypospadias repair was 19.2%, and all had received caudal epidural.
An increase of 27% in penile volume from baseline value was observed 10 min after caudal epidural placement, P < 0.05.
CONCLUSION: Penile block provided better analgesia when compared with caudal epidural in children undergoing primary hypospadias repair. Postoperative urethral fistula formation was more likely in children who received caudal epidural.
This is a prospective randomized controlled trial comparing penile block with a caudal block for children undergoing hypospadias repair. They had 27 children in each group. Their patient population was older than most contemporary series with ages ranging from 4-12 years. Penile measurements were taken before and 10 minutes after the block in both groups. Breakthrough fentanyl was given for patients with increase in mean arterial pressure (MAP) or heart rate greater than 15% from baseline. Visual analogue scores were measured at various intervals over the course of 4 days. The authors found that pain scores were significantly worse in the group receiving the caudal block. In addition, changes in MAP and heart rate were significantly higher in the caudal group. This resulted in increased use of narcotics for the caudal block group. Five patients developed urethrocutaneous fistula. All of these patients were in the caudal group. The authors speculated that this may be due to the increase in penile volume that was seen in the caudal group but not observed in the penile block group.
Both penile and caudal blocks are used routinely for hypospadias repair. There is very limited data comparing the two in a prospective fashion as these authors have done. The decision of which type of regional anesthesia to perform is often based on the preference of the surgeon or anesthesiologist involved and over time a particular type of block simply becomes part of the culture of each individual institution. The authors only included patients with midshaft to distal hypospadias. Their fistula rate of nearly 20% seems high for a primary repair in such patients. It is interesting that all of these fistulas occurred in the caudal group. More prospective studies with greater numbers of patients would be helpful to improve our care for a common procedure.
Dr. M. Chad Wallis
Division of Pediatric Urology
University of Utah
Salt Lake City, Utah, USA