Effects of botulinum toxin type a in the bladder wall of children with neurogenic bladder dysfunction: a comparison of histological features before and after injections

Conclusion: Penile block provided better analgesia when compared with caudal epidural in children undergoing primary hypospadias repair.Postoperative urethral fistula formation was more likely in children who received caudal epidural. Editorial CommentThis is a prospective randomized controlled trial comparing penile block with a caudal block for children undergoing hypospadias repair.They had 27 children in each group.Their patient population was older than most contemporary series with ages ranging from 4-12 years.Penile measurements were taken before and 10 minutes after the block in both groups.Breakthrough fentanyl was given for patients with increase in mean arterial pressure (MAP) or heart rate greater than 15% from baseline.Visual analogue scores were measured at various intervals over the course of 4 days.The authors found that pain scores were significantly worse in the group receiving the caudal block.In addition, changes in MAP and heart rate were significantly higher in the caudal group.This resulted in increased use of narcotics for the caudal block group.Five patients developed urethrocutaneous fistula.All of these patients were in the caudal group.The authors speculated that this may be due to the increase in penile volume that was seen in the caudal group but not observed in the penile block group.Both penile and caudal blocks are used routinely for hypospadias repair.There is very limited data comparing the two in a prospective fashion as these authors have done.The decision of which type of regional anesthesia to perform is often based on the preference of the surgeon or anesthesiologist involved and over time a particular type of block simply becomes part of the culture of each individual institution.The authors only included patients with midshaft to distal hypospadias.Their fistula rate of nearly 20% seems high for a primary repair in such patients.It is interesting that all of these fistulas occurred in the caudal group.More prospective studies with greater numbers of patients would be helpful to improve our care for a common procedure.

Abstract licence: CC BY

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