title: Urethrocutaneous fistula following hypospadias repair: regional anesthesia and other factors.
abstract: BACKGROUND
  Urethrocutaneous fistula is a well-known complication of hypospadias surgery. A recent prospective study by Kundra et al. (Pediatr Anesth 2012) has suggested that caudal anesthesia may increase the risk of fistula formation. We sought to evaluate this possible association and determine if any other novel factors may be associated with fistula formation.
  
  
  METHODS
  Children who underwent primary hypospadias repair between January 1, 1994 and March 31, 2013 at our tertiary care center were included in this study. Reviewed surgical data included repair type, duration of procedure, use of local anesthetic infiltration, and subcutaneous epinephrine. Analgesic factors included use of caudal and/or penile block, opioid usage, postoperative pain scores, and nausea/vomiting. Postoperative surgical complications and estimates of family household median income by zip code were also reviewed.
  
  
  RESULTS
  Fistula occurrence was not associated with caudal or penile block, severity of postoperative pain, or surgeon experience. A more proximal location of the urethral meatus, longer operating time, and use of subcutaneous epinephrine were significantly more common in patients who developed fistula. As assessed by home address zip code, distance of more than 100 miles and median household income in the bottom 25th percentile of our study population were not associated with fistula, as compared to closer distance or higher income.
  
  
  CONCLUSIONS
  In this series, we found no association between the use of caudal regional anesthesia and fistula formation. Location of the starting urethral meatus, prolonged surgical duration, and subcutaneous epinephrine use were associated with fistula formation. Our findings call into question the routine use of epinephrine in hypospadias repair.
authors.affiliation: Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Raza H
authors.identifier: http://orcid.org/0000-0002-7083-6554
authors.initials: RH
authors.lastname: Zaidi
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Nina F
authors.initials: NF
authors.lastname: Casanova
authors.affiliation: Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Bishr
authors.initials: B
authors.lastname: Haydar
authors.affiliation: Department of Anesthesiology, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Terri
authors.initials: T
authors.lastname: Voepel-Lewis
authors.affiliation: Department of Urology, University of Michigan, Ann Arbor, MI, USA.
authors.forename: Julian H
authors.initials: JH
authors.lastname: Wan
mesh_terms: D000765:Anesthesia, Conduction / Q000706:statistics & numerical data*; D016022:Case-Control Studies; D017577:Cutaneous Fistula / Q000453:epidemiology*; D004837:Epinephrine / Q000008:administration & dosage; D006801:Humans; D007021:Hypospadias / Q000453:epidemiology / Q000601:surgery*; D007223:Infant; D008297:Male; D061646:Operative Time; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D012307:Risk Factors; D012959:Socioeconomic Factors; D014522:Urethral Diseases / Q000453:epidemiology*; D014548:Urinary Fistula / Q000453:epidemiology*
chemical_list: D004837:Epinephrine
keywords: caudal anesthesia; children; hypospadias repair; socioeconomic factors; subcutaneous epinephrine; urethrocutaneous fistula