The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair

Abstract

Introduction Recent reports have suggested that caudal anesthesia may be associated with an increased risk of postoperative surgical complications. We examined our experience with caudal anesthesia in hypospadias repair to evaluate for increased risk of urethrocutaneous fistula or glanular dehiscence. Methods All hypospadias repairs performed by a single surgeon in 2001-2014 were reviewed. Staged or revision surgeries were excluded. Patient age, weight, hypospadias severity, surgery duration, month and year of surgery, caudal anesthesia use and postoperative complications were recorded. Bivariate and multivariate statistical analyses were performed. Results We identified 395 single-stage primary hypospadias repairs. Mean age was 15.6 months; 326 patients had distal (83%) and 69 had proximal (17%) hypospadias. Caudal anesthetics were used in 230 (58%) cases; 165 patients (42%) underwent local penile block at the discretion of the surgeon and/or anesthesiologist. Complications of urethrocutaneous fistula or glanular deshiscence occurred in 22 patients (5.6%) and were associated with caudal anesthetic use (OR 16.5, 95% CI 2.2-123.8, p=0.007), proximal hypospadias (OR 8.2, 95% CI 3.3-20.0, p<0.001), increased surgical duration (OR 1.01, 95% CI 1.01-1.02, p<0.001) and earlier year of practice (OR 3.0, 95% CI 1.2-7.9, p=0.03 for trend). After adjusting for confounding variables via multivariable logistic regression, both caudal anesthetic use (OR 13.4, 95% CI 1.8-101.8, p=0.01) and proximal hypospadias (OR 6.8, 95% CI 2.7-16.9, p<0.001) remained highly associated with postoperative complications. Conclusions In our experience, caudal anesthesia was associated with an over 13-fold increase in the odds of developing postoperative surgical complications in boys undergoing hypospadias repair even after adjusting for urethral meatus location. Until further investigation occurs, clinicians should carefully consider the use of caudal anesthesia for children undergoing hypospadias repair.

The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair: Comment on data sparsity

“…Sir, We have read the paper authored by Taicher et al . published in the Pediatric Anesthesia in 2017.…”

Letter to the editor regarding “The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair”

“…Sir—As pediatric urologists and active clinical researchers, we enthusiastically read the recent publication by Taicher et al . in Pediatric Anesthesia.…”

Judging causal associations in observational research on caudal anesthesia and hypospadias repair

“…Sir—I was pleased to see Dr. Polaner et al. 's editorial accompanying Dr. Taicher et al's study . Using a classic paper on bias in observational research as a guide, Dr. Polaner's conclusions can be pushed further.…”

“…Using a classic paper on bias in observational research as a guide, Dr. Polaner's conclusions can be pushed further. Dr. Taicher's study may lack internal validity due to unequal administration of caudal anesthesia (selection bias, as they described) and the possible confounding described by Dr. Polaner. When contrasting results from these retrospective studies, selection bias will vary by local practice.…”

“…While this new regression will undoubtedly be underpowered, comparing the odds ratios between regressions may suggest what is driving these results. Our study's multivariate regression showed a trend toward a negative association between caudal anesthesia and fistula in distal hypospadias, while others showed harm or a trend toward harm . These analyses should help, as would a more plausible mechanism with specific and supportive evidence.…”