title: The association between caudal anesthesia and increased risk of postoperative surgical complications in boys undergoing hypospadias repair.
abstract: BACKGROUND
  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.
authors.affiliation: Division of Pediatric Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
authors.forename: Brad M
authors.identifier: http://orcid.org/0000-0001-9985-8637
authors.initials: BM
authors.lastname: Taicher
authors.affiliation: Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: Jonathan C
authors.initials: JC
authors.lastname: Routh
authors.affiliation: Division of Pediatric Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
authors.forename: John B
authors.initials: JB
authors.lastname: Eck
authors.affiliation: Department of Urology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA.
authors.forename: Sherry S
authors.initials: SS
authors.lastname: Ross
authors.affiliation: Division of Urology, Department of Surgery, Duke University Medical Center, Durham, NC, USA.
authors.forename: John S
authors.initials: JS
authors.lastname: Wiener
authors.affiliation: Division of Pediatric Anesthesia, Department of Anesthesiology, Duke University Medical Center, Durham, NC, USA.
authors.forename: Allison K
authors.initials: AK
authors.lastname: Ross
mesh_terms: D000763:Anesthesia, Caudal / Q000009:adverse effects*; D015331:Cohort Studies; D006801:Humans; D007021:Hypospadias / Q000601:surgery*; D007223:Infant; D008297:Male; D009407:Nerve Block; D059035:Perioperative Period; D011183:Postoperative Complications / Q000453:epidemiology*; D019651:Plastic Surgery Procedures / Q000009:adverse effects; D012306:Risk; D013529:Surgical Wound Dehiscence / Q000453:epidemiology; D014548:Urinary Fistula / Q000453:epidemiology / Q000209:etiology
keywords: caudal anesthesia; hypospadias; pediatrics; regional anesthesia; surgical complications; urethrocutaneous fistula