Pain and safety outcomes of different anesthetic techniques in hypospadias surgery: a network meta-analysis of randomized clinical trials.

backgroundOptimal regional anesthesia for pediatric hypospadias repair remains controversial, with inconsistent evidence regarding postoperative pain control and complication rates. This study aimed to compare the effectiveness and safety of pudendal nerve block (PNB), penile block (PB), caudal block (CB), and general anesthesia (GA) using a network meta-analysis;Methods: A systematic search of PubMed, Embase, Scopus, Wiley, ProQuest, and Google Scholar was conducted from database inception to October 2024. Randomized controlled trials evaluating regional anesthesia techniques in children undergoing hypospadias repair were included. Primary outcomes were 24-hour postoperative pain scores and postoperative complications. A frequentist random-effects network meta-analysis was performed using the netmeta package in R. Continuous outcomes were analyzed as standardized mean differences (SMDs), and dichotomous outcomes as odds ratios (ORs). Risk of bias was assessed using the Cochrane RoB 2.0 tool, while certainty of evidence was evaluated using the Confidence in Network Meta-Analysis (CINeMA) framework;Results: Eleven randomized controlled trials involving 750 pediatric patients were included. Six studies contributed to the pain network and five to the complication network. No regional anesthesia technique demonstrated statistically significant superiority in reducing 24-hour postoperative pain compared with CB (PB vs. CB: SMD -0.91, 95% CI -1.96 to 0.14; PNB vs. CB: SMD -0.63, 95% CI -1.46 to 0.21), although substantial heterogeneity was observed (I² = 85.5%). Treatment ranking suggested that PB and PNB had higher probabilities of improved analgesia than CB; however, these rankings reflected relative probabilities rather than clinical superiority. Similarly, no significant differences in postoperative complication rates were identified among CB, PB, and GA (all p > 0.05). Risk of bias was generally low across studies. CINeMA rated the certainty of evidence as low for pain outcomes because of imprecision and incoherence, and moderate for complication outcomes due to imprecision;Conclusion: Current evidence does not demonstrate statistically significant superiority of any regional anesthesia technique for pediatric hypospadias repair. Although PB and PNB showed higher probabilities of improved postoperative analgesia, the certainty of evidence remains limited by heterogeneity and imprecision. Additional well-designed randomized controlled trials with standardized reporting are needed to establish the comparative effectiveness and safety of regional anesthesia techniques in pediatric hypospadias surgery.