Does caudal analgesia increase the rates of urethrocutaneous fistula formation after hypospadias repair? Systematic review and meta-analysis

Abstract

Introduction: Caudal block analgesia is administered to lower the requirements of systemic and inhaled anesthetic drugs during hypospadias surgery. However, recent reports, all clustered in a short time-span have generated controversial and mutually opposing results while evaluating caudal block as an independent risk factor for urethroplasty-related complications after hypospadias repair. There is no consensus statement on the role of caudal block analgesia in formation of urethrocutaneous fistula (UCF) after hypospadias surgery. We performed a systematic review and meta-analysis of the studies evaluating the relative rates of UCF formation after hypospadias surgery in patients who were administered caudal block analgesia versus in those who were not. Methods: Electronic searches were performed using PubMed, PubMed Central, Google Scholar, Ovid, and the Cochrane library. Statistical analysis was performed using a fixed-effect model, odds ratios, risk ratios (RR), and heterogeneity (I 2 ) were calculated. Funnel plot was used to assess for publication bias. Results: Seven studies with 1706 patients were included. Caudal block analgesia is associated with a significantly higher risk of UCF formation (RR: 1.81; 95% confidence interval [CI]: 1.30–2.53), ( P = 0.0004) and other urethroplasty-related complications (RR 2.01; 95% CI: 1.48–2.74), ( P < 0.00001) after hypospadias surgery. Funnel plots indicate some publication bias. Conclusions: In patients undergoing hypospadias repair, administration of caudal analgesia is associated with a higher risk of UCF formation and other urethroplasty-related complications.

Comparison of Urethrocutaneous Fistula Rate After Single Dartos and Double Dartos Tubularized Incised Plate Urethroplasty in Pediatric Hypospadias

“…Suture material, infection, previous operations, catheterization, surgical skills like tension-free anastomosis and prevention of epithelium eversion, all are implicated in prevention of fistula formation [ 6 , 13 ]. Another important factor in fistula prevention is the use of intermediate layer between neourethra and skin.…”

“…Post urethroplasty major complications include urethrocutaneous fistula, hematoma, skin necrosis, meatal stenosis and urethral disruption, but the most common complication is urethrocutaneous fistula with overall range from 0% to 35% [ 1 , 6 ].…”

“…The causes of post urethroplasty fistula include local factors like infection, local ischemia, an improper technique, poor tissue handling, distal obstruction due to meatal stenosis, severity of hypospadias, patient factors, everted edges of epithelium in neourethra, and prolonged tourniquet. Systemic factors causing immunodeficiency and nutritional factors are also implicated [ 6 ]. To reduce the rate of urethrocutaneous fistula, different techniques have been used and one of these is tissue inter-positioning of dartos fascial flap between the neourethra and skin [ 7 ].…”

A Perspective upon Systematic Review and Meta-analysis

“…Kundra et al . [ 6 ] conducted a study to compare the analgesic effect of penile block vis-à-vis caudal epidural in hypospadias repair. They reported that all the urethra-cutaneous fistula (UCF) in the study cohort were observed in the caudal epidural group.…”

“…A systematic review and meta-analysis of the seven studies was conducted to pool the individual data and generate a common conclusion. [ 6 ]…”