Hypospadias repair - Revision history

Chris.Rishel at 13:57, 1 August 2022

2022-08-01T13:57:53Z

← Older revision		Revision as of 06:57, 1 August 2022
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	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]
	~~{{DEFAULTSORT:Hypospadias Repair}}~~
	~~<references />~~
	[[Category:Urology]]		[[Category:Urology]]
	[[Category:Pediatric urology]]		[[Category:Pediatric urology]]
	~~[[Category:Urologic]]~~		<references />
	~~[[Category:Pediatric urologic surgery]]~~

Chris.Rishel: Chris.Rishel moved page Hypospadias to Hypospadias repair without leaving a redirect

2022-08-01T13:57:06Z

Chris.Rishel moved page Hypospadias to Hypospadias repair without leaving a redirect

← Older revision

Revision as of 06:57, 1 August 2022

Chris.Rishel at 13:56, 1 August 2022

2022-08-01T13:56:57Z

← Older revision		Revision as of 06:56, 1 August 2022
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	~~{{DISPLAYTITLE:Hypospadias Repair}}~~
	{{Infobox surgical procedure		{{Infobox surgical procedure
	\| anesthesia_type = General		\| anesthesia_type = General
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	\| considerations_postoperative = Pain control		\| considerations_postoperative = Pain control
	}}		}}
			A '''hypospadias repair''' is a urological procedure which corrects the congenital misplacement of the male urethral meatus.
	== Overview ==		== Overview ==

CFitzgerald at 18:32, 31 July 2022

2022-07-31T18:32:56Z

← Older revision		Revision as of 11:32, 31 July 2022
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	*** Most commonly clonidine is added at 1 mcg/mL of local anesthetic		*** Most commonly clonidine is added at 1 mcg/mL of local anesthetic
	**** Prolongs the analgesic effects of the block, while not necessarily increasing the block density<ref>{{Cite journal\|last=Hansen\|first=T.G.\|last2=Henneberg\|first2=S.W.\|last3=Walther-Larsen\|first3=S\|last4=Lund\|first4=J\|last5=Hansen\|first5=M\|date=2004\|title=Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study\|url=http://dx.doi.org/10.1093/bja/aeh028\|journal=British Journal of Anaesthesia\|volume=92\|issue=2\|pages=223–227\|doi=10.1093/bja/aeh028\|issn=0007-0912}}</ref>		**** Prolongs the analgesic effects of the block, while not necessarily increasing the block density<ref>{{Cite journal\|last=Hansen\|first=T.G.\|last2=Henneberg\|first2=S.W.\|last3=Walther-Larsen\|first3=S\|last4=Lund\|first4=J\|last5=Hansen\|first5=M\|date=2004\|title=Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study\|url=http://dx.doi.org/10.1093/bja/aeh028\|journal=British Journal of Anaesthesia\|volume=92\|issue=2\|pages=223–227\|doi=10.1093/bja/aeh028\|issn=0007-0912}}</ref>
	** Associated with better operating conditions and less blood loss during the surgery<ref>{{Cite journal\|last=Gunter\|first=Joel B.\|last2=Forestner\|first2=John E.\|last3=Manley\|first3=Charles B.\|date=1990\|title=Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair\|url=http://dx.doi.org/10.1016/s0022-5347(17)39509-5\|journal=Journal of Urology\|volume=144\|issue=2 Part 2\|pages=517–519\|doi=10.1016/s0022-5347(17)39509-5\|issn=0022-5347}}</ref>		** Associated with better operating conditions and slightly less blood loss during the surgery<ref>{{Cite journal\|last=Gunter\|first=Joel B.\|last2=Forestner\|first2=John E.\|last3=Manley\|first3=Charles B.\|date=1990\|title=Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair\|url=http://dx.doi.org/10.1016/s0022-5347(17)39509-5\|journal=Journal of Urology\|volume=144\|issue=2 Part 2\|pages=517–519\|doi=10.1016/s0022-5347(17)39509-5\|issn=0022-5347}}</ref>
	** Of note, there have been studies published that indicate caudal placement increases risk of urethrocutaneous fistula formation<ref>{{Cite journal\|last=Kim\|first=M. H.\|last2=Im\|first2=Y. J.\|last3=Kil\|first3=H. K.\|last4=Han\|first4=S. W.\|last5=Joe\|first5=Y. E.\|last6=Lee\|first6=J. H.\|date=2016\|title=Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study\|url=https://onlinelibrary.wiley.com/doi/10.1111/anae.13463\|journal=Anaesthesia\|language=en\|volume=71\|issue=7\|pages=773–778\|doi=10.1111/anae.13463}}</ref>, a known complication of the surgical procedure. Most findings are associations without causation and other retrospective studies have failed to find the same link. <ref>{{Cite journal\|last=Zaidi\|first=Raza H.\|last2=Casanova\|first2=Nina F.\|last3=Haydar\|first3=Bishr\|last4=Voepel-Lewis\|first4=Terri\|last5=Wan\|first5=Julian H.\|date=2015\|editor-last=Bosenberg\|editor-first=Adrian\|title=Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors\|url=https://onlinelibrary.wiley.com/doi/10.1111/pan.12719\|journal=Pediatric Anesthesia\|language=en\|volume=25\|issue=11\|pages=1144–1150\|doi=10.1111/pan.12719}}</ref><ref>{{Cite journal\|last=Zhu\|first=Change\|last2=Wei\|first2=Rong\|last3=Tong\|first3=Yiru\|last4=Liu\|first4=Junjun\|last5=Song\|first5=Zhaomeng\|last6=Zhang\|first6=Saiji\|date=2019\|title=Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis\|url=https://rapm.bmj.com/content/44/2/259\|journal=Regional Anesthesia & Pain Medicine\|language=en\|volume=44\|issue=2\|pages=259–267\|doi=10.1136/rapm-2018-000022\|issn=1098-7339\|pmid=30700621}}</ref>		** Of note, there have been studies published that indicate caudal placement increases risk of urethrocutaneous fistula formation<ref>{{Cite journal\|last=Kim\|first=M. H.\|last2=Im\|first2=Y. J.\|last3=Kil\|first3=H. K.\|last4=Han\|first4=S. W.\|last5=Joe\|first5=Y. E.\|last6=Lee\|first6=J. H.\|date=2016\|title=Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study\|url=https://onlinelibrary.wiley.com/doi/10.1111/anae.13463\|journal=Anaesthesia\|language=en\|volume=71\|issue=7\|pages=773–778\|doi=10.1111/anae.13463}}</ref>, a known common complication of the surgical procedure. Most findings are associations without causation and other retrospective studies have failed to find the same link. <ref>{{Cite journal\|last=Zaidi\|first=Raza H.\|last2=Casanova\|first2=Nina F.\|last3=Haydar\|first3=Bishr\|last4=Voepel-Lewis\|first4=Terri\|last5=Wan\|first5=Julian H.\|date=2015\|editor-last=Bosenberg\|editor-first=Adrian\|title=Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors\|url=https://onlinelibrary.wiley.com/doi/10.1111/pan.12719\|journal=Pediatric Anesthesia\|language=en\|volume=25\|issue=11\|pages=1144–1150\|doi=10.1111/pan.12719}}</ref><ref>{{Cite journal\|last=Zhu\|first=Change\|last2=Wei\|first2=Rong\|last3=Tong\|first3=Yiru\|last4=Liu\|first4=Junjun\|last5=Song\|first5=Zhaomeng\|last6=Zhang\|first6=Saiji\|date=2019\|title=Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis\|url=https://rapm.bmj.com/content/44/2/259\|journal=Regional Anesthesia & Pain Medicine\|language=en\|volume=44\|issue=2\|pages=259–267\|doi=10.1136/rapm-2018-000022\|issn=1098-7339\|pmid=30700621}}</ref>
	* Penile block by surgeon may be considered with simple distal defects. There may be additional postoperative pain control with preincision and postoperative penile blocks vs single-shot blocks <ref>{{Cite journal\|last=Chhibber\|first=Ashwani K.\|last2=Perkins\|first2=Fredrick M.\|last3=Rabinowitz\|first3=Ronald\|last4=Vogt\|first4=Alison W.\|last5=Hulbert\|first5=William C.\|date=1997\|title=Penile Block Timing for Postoperative Analgesia of Hypospadias Repair in Children\|url=http://dx.doi.org/10.1097/00005392-199709000-00118\|journal=The Journal of Urology\|pages=1156–1159\|doi=10.1097/00005392-199709000-00118\|issn=0022-5347}}</ref>		* Penile block by surgeon may be considered with simple distal defects. There may be additional postoperative pain control with preincision and postoperative penile blocks vs single-shot blocks <ref>{{Cite journal\|last=Chhibber\|first=Ashwani K.\|last2=Perkins\|first2=Fredrick M.\|last3=Rabinowitz\|first3=Ronald\|last4=Vogt\|first4=Alison W.\|last5=Hulbert\|first5=William C.\|date=1997\|title=Penile Block Timing for Postoperative Analgesia of Hypospadias Repair in Children\|url=http://dx.doi.org/10.1097/00005392-199709000-00118\|journal=The Journal of Urology\|pages=1156–1159\|doi=10.1097/00005392-199709000-00118\|issn=0022-5347}}</ref>

CFitzgerald: emergence delirium

2022-07-31T18:31:10Z

emergence delirium

← Older revision		Revision as of 11:31, 31 July 2022
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	* Deep vs awake extubation		* Deep vs awake extubation
			*Emergence delirium risk age-dependent
			**Dexmedetomidine 0.3 mcg/kg IV PRN

	== Postoperative management ==		== Postoperative management ==

CFitzgerald: minor edits for consistancy

2022-07-31T18:24:48Z

minor edits for consistancy

← Older revision		Revision as of 11:24, 31 July 2022
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	=== Indications ===		=== Indications ===

	* Congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening (meatus).		* Congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening (meatus)
	* ~~Relatively~~ common congenital defect seen in approximately 1:~~350~~ births		* Very common congenital defect seen in approximately 1:200 births<ref>{{Cite journal\|last=Mai\|first=Cara T.\|last2=Isenburg\|first2=Jennifer\|last3=Langlois\|first3=Peter H.\|last4=Alverson\|first4=CJ\|last5=Gilboa\|first5=Suzanne M.\|last6=Rickard\|first6=Russel\|last7=Canfield\|first7=Mark A.\|last8=Anjohrin\|first8=Suzanne B.\|last9=Lupo\|first9=Philip J.\|last10=Jackson\|first10=Deanna R.\|last11=Stallings\|first11=Erin B.\|date=2015\|title=Population-based birth defects data in the United States, 2008 to 2012: Presentation of state-specific data and descriptive brief on variability of prevalence\|url=http://dx.doi.org/10.1002/bdra.23461\|journal=Birth Defects Research Part A: Clinical and Molecular Teratology\|volume=103\|issue=11\|pages=972–993\|doi=10.1002/bdra.23461\|issn=1542-0752}}</ref><ref>{{Cite journal\|last=Paulozzi\|first=Leonard J.\|last2=Erickson\|first2=J. David\|last3=Jackson\|first3=Richard J.\|date=1997-11-01\|title=Hypospadias Trends in Two US Surveillance Systems\|url=http://dx.doi.org/10.1542/peds.100.5.831\|journal=Pediatrics\|volume=100\|issue=5\|pages=831–834\|doi=10.1542/peds.100.5.831\|issn=1098-4275}}</ref>
	* Subdivided by severity/location of developmental abnormality		* Subdivided by severity/location of developmental abnormality
	** Forme fruste of hypospadias: Incomplete/partial hypospadias; typically not surgically corrected		** Forme fruste of hypospadias: Incomplete/partial hypospadias; typically not surgically corrected
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	=== Regional and neuraxial techniques ===		=== Regional and neuraxial techniques ===

	* Caudal ~~Epidural~~		* [[Caudal block\|Caudal block (caudal epidural)]]
	** Placed after induction of anesthesia, intravenous access, and airway management		** Placed after induction of anesthesia, intravenous access, and airway management
	** Additives to local can include clonidine, ketamine, and opiates		** Additives to local can include clonidine, ketamine, and opiates
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	[[Category:Surgical procedures]]		[[Category:Surgical procedures]]
	{{DEFAULTSORT:Hypospadias Repair}}		{{DEFAULTSORT:Hypospadias Repair}}
			<references />
			[[Category:Urology]]
			[[Category:Pediatric urology]]
			[[Category:Urologic]]
			[[Category:Pediatric urologic surgery]]

CFitzgerald: inital page draft

2022-07-31T18:15:15Z

inital page draft

New page

{{DISPLAYTITLE:Hypospadias Repair}}
{{Infobox surgical procedure
| anesthesia_type = General
| airway = [[ETT]] or [[LMA]]
| lines_access = [[PIV]]
| monitors = Standard
| considerations_preoperative = None
| considerations_intraoperative = ± [[caudal block]] or penile block
| considerations_postoperative = Pain control
}}

== Overview ==

=== Indications ===

* Congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening (meatus).
* Relatively common congenital defect seen in approximately 1:350 births
* Subdivided by severity/location of developmental abnormality
** Forme fruste of hypospadias: Incomplete/partial hypospadias; typically not surgically corrected
** Standard hypospadias associated with normal foreskin, penile length, and glans size. There may be normal variable penile curvature; typically a distal meatus defect.
** Severe hypospadias associated with proximal defects including the scrotum or perineum and/or an abnormally small glans size with severe curvature abnormalities

* Elective procedure in most cases

* Most often considered and recommended in cases with severe cosmetic abnormalities, defects leading to limitations in voiding positions, severe curvature abnormalities that may inhibit intercourse, and concern for future fertility issues

== Preoperative management ==

=== Patient evaluation ===
{| class="wikitable"
|+
!System
!Considerations
|-
|Airway
|
|-
|Neurologic
|
|-
|Cardiovascular
|
|-
|Pulmonary
|
|-
|Gastrointestinal
|
|-
|Hematologic
|
|-
|Renal
|Typically normal, but review available labs and imaging if other abnormalities are present
|-
|Endocrine
|
|-
|Other
|Patients are typically healthy children
|}

=== Patient preparation and premedication ===

* Anxiolysis, if needed, with midazolam (PO)
* Acetaminophen PO (or PR prior to procedure)

=== Regional and neuraxial techniques ===

* Caudal Epidural
** Placed after induction of anesthesia, intravenous access, and airway management
** Additives to local can include clonidine, ketamine, and opiates
*** Most commonly clonidine is added at 1 mcg/mL of local anesthetic
**** Prolongs the analgesic effects of the block, while not necessarily increasing the block density<ref>{{Cite journal|last=Hansen|first=T.G.|last2=Henneberg|first2=S.W.|last3=Walther-Larsen|first3=S|last4=Lund|first4=J|last5=Hansen|first5=M|date=2004|title=Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study|url=http://dx.doi.org/10.1093/bja/aeh028|journal=British Journal of Anaesthesia|volume=92|issue=2|pages=223–227|doi=10.1093/bja/aeh028|issn=0007-0912}}</ref>
** Associated with better operating conditions and less blood loss during the surgery<ref>{{Cite journal|last=Gunter|first=Joel B.|last2=Forestner|first2=John E.|last3=Manley|first3=Charles B.|date=1990|title=Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair|url=http://dx.doi.org/10.1016/s0022-5347(17)39509-5|journal=Journal of Urology|volume=144|issue=2 Part 2|pages=517–519|doi=10.1016/s0022-5347(17)39509-5|issn=0022-5347}}</ref>
** Of note, there have been studies published that indicate caudal placement increases risk of urethrocutaneous fistula formation<ref>{{Cite journal|last=Kim|first=M. H.|last2=Im|first2=Y. J.|last3=Kil|first3=H. K.|last4=Han|first4=S. W.|last5=Joe|first5=Y. E.|last6=Lee|first6=J. H.|date=2016|title=Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study|url=https://onlinelibrary.wiley.com/doi/10.1111/anae.13463|journal=Anaesthesia|language=en|volume=71|issue=7|pages=773–778|doi=10.1111/anae.13463}}</ref>, a known complication of the surgical procedure. Most findings are associations without causation and other retrospective studies have failed to find the same link. <ref>{{Cite journal|last=Zaidi|first=Raza H.|last2=Casanova|first2=Nina F.|last3=Haydar|first3=Bishr|last4=Voepel-Lewis|first4=Terri|last5=Wan|first5=Julian H.|date=2015|editor-last=Bosenberg|editor-first=Adrian|title=Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors|url=https://onlinelibrary.wiley.com/doi/10.1111/pan.12719|journal=Pediatric Anesthesia|language=en|volume=25|issue=11|pages=1144–1150|doi=10.1111/pan.12719}}</ref><ref>{{Cite journal|last=Zhu|first=Change|last2=Wei|first2=Rong|last3=Tong|first3=Yiru|last4=Liu|first4=Junjun|last5=Song|first5=Zhaomeng|last6=Zhang|first6=Saiji|date=2019|title=Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis|url=https://rapm.bmj.com/content/44/2/259|journal=Regional Anesthesia & Pain Medicine|language=en|volume=44|issue=2|pages=259–267|doi=10.1136/rapm-2018-000022|issn=1098-7339|pmid=30700621}}</ref>
* Penile block by surgeon may be considered with simple distal defects. There may be additional postoperative pain control with preincision and postoperative penile blocks vs single-shot blocks <ref>{{Cite journal|last=Chhibber|first=Ashwani K.|last2=Perkins|first2=Fredrick M.|last3=Rabinowitz|first3=Ronald|last4=Vogt|first4=Alison W.|last5=Hulbert|first5=William C.|date=1997|title=Penile Block Timing for Postoperative Analgesia of Hypospadias Repair in Children|url=http://dx.doi.org/10.1097/00005392-199709000-00118|journal=The Journal of Urology|pages=1156–1159|doi=10.1097/00005392-199709000-00118|issn=0022-5347}}</ref>

== Intraoperative management ==

=== Monitoring and access ===

* Standard monitors
* PIV x1

=== Induction and airway management ===

* Inhalational induction followed by PIV placement
* Airway
** ETT vs LMA (most common)
** Complex repair with buccal graft may require an oral RAE ETT

=== Positioning ===

* Supine

=== Maintenance and surgical considerations ===

* Volatile agents (most common)
* TIVA with propofol ± fentanyl boluses or remifentanil gtt
** the need for intraoperative narcotics should be significantly lowered or eliminated with a working caudal block

=== Emergence ===

* Deep vs awake extubation

== Postoperative management ==

=== Disposition ===

* PACU then Home

=== Pain management ===

* Pain control requirements depend on the extent of the repair, scheduled dosing of non-opiate analgesics should likely be started before the termination of caudal effects (if one was performed)
* Morphine IV (0.025-0.05 mg/kg) with possible transition to PO opiate prior to discharge at surgical team's discretion; but not typically required
* Additional acetaminophen (10-15 mg/kg with a q6hr dosing interval) and/or ibuprofen is generally adequate for pain control

=== Potential complications ===

* Urethrocutaneous fistula
* Urethral stricture
* Urethral diverticulum
* Urinary extravasation

== Procedure variants ==

{| class="wikitable wikitable-horizontal-scroll"
|+
!
!Variant 1
!Variant 2
|-
|Unique considerations
|
|
|-
|Position
|
|
|-
|Surgical time
|
|
|-
|EBL
|
|
|-
|Postoperative disposition
|
|
|-
|Pain management
|
|
|-
|Potential complications
|
|
|}

== References ==

[[Category:Surgical procedures]]
{{DEFAULTSORT:Hypospadias Repair}}