Hypospadias repair

Hypospadias repair

Anesthesia type	General
Airway	ETT or LMA
Lines and access	PIV
Monitors	Standard
Primary anesthetic considerations
Preoperative	None
Intraoperative	± caudal block or penile block
Postoperative	Pain control
Article quality
Editor rating	Comprehensive
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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
• 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
  • Associated with better operating conditions and less blood loss during the surgery
  • Of note, there have been studies published that indicate caudal placement increases risk of urethrocutaneous fistula formation, a known complication of the surgical procedure. Most findings are associations without causation and other retrospective studies have failed to find the same link.
• 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

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

	Variant 1	Variant 2
Unique considerations
Position
Surgical time
EBL
Postoperative disposition
Pain management
Potential complications