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Opioid Sparing Pain Management Following Hypospadias Repair
Bhalaajee Meenakshi-Sundaram, MD, Jeein Yoon, MD, Dominic Frimberger, MD, Adam Rensing, MD.
Oklahoma Children's Hospital at OU Health, Oklahoma City, OK, USA.

BACKGROUND: Appropriate pain management following surgery is essential to an expedient and effective recovery from surgery. In children, this is particularly important as children may be unable to verbalize their pain. However, overprescription of opioid pain medication may lead to misuse and dependence, particularly in previously opioid na´ve patients. We sought to determine if opioids could be excluded from the outpatient medication regimen following hypospadias repair in boys while ensuring pain was still well managed via a randomized controlled trial.
METHODS: Boys undergoing hypospadias repair at our center between July 2020 and June 2021 were randomized to receive no opioids vs opioids (oxycodone 0.1 mg/kg prn x 10 doses) as part of their outpatient pain regimen. Boys in both groups received preop caudal blocks, postop ketorolac, and scheduled Acetaminophen and Ibuprofen as part of their outpatient regimens. A validated questionnaire, the Parents' Postoperative Pain Measure (PPPM), was administered to families by phone on postoperative days 1, 3, and 5. Patients over age 2 and those who required admission were excluded.
RESULTS: 60 hypospadias repairs were performed in the study period and 39 (28 distal, 11 proximal) were included. 23 patients were in the "opioid free" group and 16 received prescriptions. The two groups were not statistically different in age, weight, type of repair, or length of surgery. In the opioid group, a mean of 8 doses were given and 4/16 patients used all 10 doses. However, the median pain scores, as measured by the PPPM, were not statistically different in the two groups. Additionally, no statistical difference in pain scores was noted in the two groups when the repairs were stratified by hypospadias severity (proximal vs. distal).
CONCLUSIONS: In outpatient pediatric hypospadias repairs, opioids can be safely omitted from the postoperative pain management regimen without contributing to worsening pain. Physician prescribing patterns may lead to opioid use in patients whose pain does not warrant it. To our knowledge, this is the first randomized study assessing pain control following pediatric hypospadias repair.

PPPM score - All Repairs
PODMedian PPPM score - no opioids (n = 23)Median PPPM score - opioids (n = 16)p-value
13.0 [2.0-4.5]3.0 [2.0-5.0]0.63
32.0 [1.0-3.5]3.5 [2.0-5.25]0/15
51.0 [1.0-1.5]1.0 [1.0-2.75]0.60

PPPM score - Distal Repairs
PODMedian PPPM score - no opioids (n = 18)Median PPPM score - opioids (n = 10)p-value
13.5 [1.25-4.75]3.0 [2.0-3.75]0.79
32.0 [1.0-3.5]4.0 [2.0-6.75]0.07
50.0 [0.0-1.0]1.0 [0.75-2.25]0.21

PPPM score - Proximal Repairs
PODMedian PPPM score - no opioids (n = 5)Median PPPM score - opioids (n = 6)p-value
12.0 [2.0-3.0]6.0 [2.0-8.75]0.51
33.0 [2.5-4.0]2.5 [2.0-3.75]0.57
51.0 [0.0-1.0]1.0 [0.5-2.5]0.07

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