Hypospadias Repair (Pediatric)
Patient phenotype
Boys 6-18 months typically (can be older for staged repairs). Otherwise healthy. Hypospadias is congenital — abnormal urethral meatus location. Outpatient procedure.
Procedure
Reconstruct urethra to glans, correct chordee (penile curvature). 60-180 min depending on severity. Often combined with caudal block for postop pain.
Anesthetic plan
Mask induction → IV → GA + LMA. Caudal block (single shot 0.5-1 mL/kg of 0.25% bupi) for postop analgesia + reduced volatile requirement. Avoid epi in caudal (penile vasoconstriction risk).
Setup
- ·Pediatric monitors + temp
- ·PIV after asleep
- ·LMA pediatric size
- ·Caudal block kit + 22g caudal needle
- ·BAIR hugger (long surgery, small patient)
- ·Penile block alternative if caudal contraindicated
Biggest concerns by phase
URI assessment + parent communication
Standard pediatric URI screen. Explain mask induction + caudal block to parents — emphasize parent presence option, no IV until asleep, PACU return.
Mask induction + caudal block timing
Sevo + N₂O mask induction. Once asleep, IV access + intubation/LMA. Position lateral (knees to chest) for caudal block AFTER induction but before incision.
Caudal block — landmarks + dose
Sacral hiatus between cornua, palpable. 22g needle perpendicular to skin, then 45° advancement after pop through sacrococcygeal ligament. 0.5-1 mL/kg of 0.25% bupi (typical 5-10 mL). NO EPINEPHRINE (penile vasoconstriction = ischemia). Test dose for IV.
Caudal complications
IV injection (LAST), intrathecal (high spinal), dural puncture (PDPH rare in kids), infection (sterile technique). Most caudals work + uneventful.
Reduced volatile + opioid needs after caudal
Effective caudal → MAC requirement drops 30-50%. Opioid often unnecessary intraop. Decreases emergence delirium + speeds wake-up.
Postop: catheter care, prevent bladder spasm
Urinary catheter remains 7-14 days. Bladder spasm common (treat with oxybutynin). Pain typically well-controlled with caudal × 6-8h then APAP/ibuprofen. Discharge same day.
Mock-defense scenarios
Practice answering these out loud. The probes show what an examiner is listening for.
8-month-old for distal hypospadias repair. After mask induction + IV access, you place a caudal block with 8 mL of 0.25% bupi. Within 60 sec the patient becomes profoundly bradycardic (HR 50) and hypotensive (BP 50/30). What's happening and what do you do?
What an examiner probes for
- ▹Possible: high spinal (subarachnoid injection), LAST, vasovagal
- ▹Action: 100% O₂, atropine 0.02 mg/kg, fluid bolus, vasopressor
- ▹If suspected LAST: lipid emulsion 1.5 mL/kg
- ▹Support airway if respiratory depression
- ▹Recognize: caudal subarachnoid injection is rare but possible — manage as high spinal
Sources
- Coté Pediatric Anesthesia 7e
- AAP perioperative pediatric guidelines
Anatomy reference
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