Difference between revisions of "Hypospadias repair"
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{{Infobox surgical procedure | {{Infobox surgical procedure | ||
| anesthesia_type = General | | anesthesia_type = General | ||
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| considerations_postoperative = Pain control | | considerations_postoperative = Pain control | ||
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A '''hypospadias repair''' is a urological procedure which corrects the congenital misplacement of the male urethral meatus. | |||
== Overview == | == Overview == | ||
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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> | ||
| Line 104: | Line 103: | ||
* Deep vs awake extubation | * Deep vs awake extubation | ||
*Emergence delirium risk age-dependent | |||
**Dexmedetomidine 0.3 mcg/kg IV PRN | |||
== Postoperative management == | == Postoperative management == | ||
| Line 164: | Line 165: | ||
[[Category:Surgical procedures]] | [[Category:Surgical procedures]] | ||
[[Category:Urology]] | [[Category:Urology]] | ||
[[Category:Pediatric urology]] | [[Category:Pediatric urology]] | ||
<references /> | |||
Latest revision as of 05:57, 1 August 2022
Hypospadias repair
| Anesthesia type |
General |
|---|---|
| Airway | |
| Lines and access | |
| Monitors |
Standard |
| Primary anesthetic considerations | |
| Preoperative |
None |
| Intraoperative |
± caudal block or penile block |
| Postoperative |
Pain control |
| Article quality | |
| Editor rating | |
| User likes | 0 |
A hypospadias repair is a urological procedure which corrects the congenital misplacement of the male urethral meatus.
Overview
Indications
- Congenital anomaly of the male urethra that results in abnormal ventral placement of the urethral opening (meatus)
- Very common congenital defect seen in approximately 1:200 births[1][2]
- 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
| 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 block (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[3]
- Most commonly clonidine is added at 1 mcg/mL of local anesthetic
- Associated with better operating conditions and slightly less blood loss during the surgery[4]
- Of note, there have been studies published that indicate caudal placement increases risk of urethrocutaneous fistula formation[5], 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. [6][7]
- 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 [8]
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
- Emergence delirium risk age-dependent
- Dexmedetomidine 0.3 mcg/kg IV PRN
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
| Variant 1 | Variant 2 | |
|---|---|---|
| Unique considerations | ||
| Position | ||
| Surgical time | ||
| EBL | ||
| Postoperative disposition | ||
| Pain management | ||
| Potential complications |
References
- ↑ Mai, Cara T.; Isenburg, Jennifer; Langlois, Peter H.; Alverson, CJ; Gilboa, Suzanne M.; Rickard, Russel; Canfield, Mark A.; Anjohrin, Suzanne B.; Lupo, Philip J.; Jackson, Deanna R.; Stallings, Erin B. (2015). "Population-based birth defects data in the United States, 2008 to 2012: Presentation of state-specific data and descriptive brief on variability of prevalence". Birth Defects Research Part A: Clinical and Molecular Teratology. 103 (11): 972–993. doi:10.1002/bdra.23461. ISSN 1542-0752.
- ↑ Paulozzi, Leonard J.; Erickson, J. David; Jackson, Richard J. (1997-11-01). "Hypospadias Trends in Two US Surveillance Systems". Pediatrics. 100 (5): 831–834. doi:10.1542/peds.100.5.831. ISSN 1098-4275.
- ↑ Hansen, T.G.; Henneberg, S.W.; Walther-Larsen, S; Lund, J; Hansen, M (2004). "Caudal bupivacaine supplemented with caudal or intravenous clonidine in children undergoing hypospadias repair: a double-blind study". British Journal of Anaesthesia. 92 (2): 223–227. doi:10.1093/bja/aeh028. ISSN 0007-0912.
- ↑ Gunter, Joel B.; Forestner, John E.; Manley, Charles B. (1990). "Caudal Epidural Anesthesia Reduces Blood Loss During Hypospadias Repair". Journal of Urology. 144 (2 Part 2): 517–519. doi:10.1016/s0022-5347(17)39509-5. ISSN 0022-5347.
- ↑ Kim, M. H.; Im, Y. J.; Kil, H. K.; Han, S. W.; Joe, Y. E.; Lee, J. H. (2016). "Impact of caudal block on postoperative complications in children undergoing tubularised incised plate urethroplasty for hypospadias repair: a retrospective cohort study". Anaesthesia. 71 (7): 773–778. doi:10.1111/anae.13463.
- ↑ Zaidi, Raza H.; Casanova, Nina F.; Haydar, Bishr; Voepel-Lewis, Terri; Wan, Julian H. (2015). Bosenberg, Adrian (ed.). "Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors". Pediatric Anesthesia. 25 (11): 1144–1150. doi:10.1111/pan.12719.
- ↑ Zhu, Change; Wei, Rong; Tong, Yiru; Liu, Junjun; Song, Zhaomeng; Zhang, Saiji (2019). "Analgesic efficacy and impact of caudal block on surgical complications of hypospadias repair: a systematic review and meta-analysis". Regional Anesthesia & Pain Medicine. 44 (2): 259–267. doi:10.1136/rapm-2018-000022. ISSN 1098-7339. PMID 30700621.
- ↑ Chhibber, Ashwani K.; Perkins, Fredrick M.; Rabinowitz, Ronald; Vogt, Alison W.; Hulbert, William C. (1997). "Penile Block Timing for Postoperative Analgesia of Hypospadias Repair in Children". The Journal of Urology: 1156–1159. doi:10.1097/00005392-199709000-00118. ISSN 0022-5347.
Top contributors: Chase Fitzgerald and Chris Rishel