Decisional Regret after Distal Hypospadias Repair: Single Institution Prospective Analysis of Factors Associated with Subsequent Parental Remorse or Distress

Parent decisional regret regarding neonatal circumcision in an American outpatient pediatric urology clinic

INTRODUCTION/BACKGROUND

Requests for circumcision revision are common in our American pediatric urology clinic. As parents are the surrogate decision maker for their child, there are several influences that can impact a parent's decision for or against circumcision.

OBJECTIVE

We sought to assess parents' regret regarding their child's circumcision status and to correlate regret to factors that might have affected the original decision.

STUDY DESIGN

From March 2023 to January 2024, we surveyed parents who brought their male child to our office for any reason, independent of circumcision status. The questionnaire was two-fold: a validated Decisional Regret Scale (DRS) (0-100 where higher scores = higher regret) and our questions regarding their decision-making process and outcome. Regret scores served as a function of each of the independent decision making and outcome variables.

RESULTS

Overall, decisional regret scores from both uncircumcised and circumcised parent groups were positively skewed with a median 0, mean 22, and ranged from 0 to 75. For those circumcised (n = 91), the median regret score was 0 (IQR 0-25). For those uncircumcised (n = 28), median regret score was 0 (IQR 0-24). Overall, 55% of both groups reported no regret (DRS = 0), 24% had low-mild regret (DRS 5-25), and 21% yielded moderate-strong regret (DRS 30-100). Parents who felt they made an informed decision or were counseled by any physician had lower regret scores. Parents who presented for issues related to their child's uncircumcised or circumcised penis (DRS score 37.5 and 25 respectively) had higher regret scores.

DISCUSSION

We found that a large portion of parents expressed no regret regarding their decision to have or not have their child circumcised (55%). There also was no difference in median regret scores between parent groups. However, a significant portion of parents did express moderate-strong regret (21%) and several influential factors were correlated with regret scores. These factors included informed decision making, physician counseling, appearance satisfaction, and problems related to their child's circumcised or uncircumcised penis. These factors are supported by other literature using the DRS and population studies. The limitations of our study included the limited recruitment of participants and potential time dependent bias of responses.

CONCLUSION

One in five parents of both circumcised and uncircumcised boys expressed moderate to strong regret regarding their decision about neonatal circumcision in our pediatric urology clinic. Our data suggests that ensuring parents have sufficient counseling prior to a decision regarding neonatal circumcision is important.

Caregiver decisional regret following reconstructive bladder surgery in children with neurogenic bladder

BACKGROUND

Surgical management for neurogenic bladder requires complex decision-making by physicians, patients, and caregivers. Assessing decisional regret (DR) as a patient-reported outcome among caregivers could inform future counseling and shared decision-making.

OBJECTIVE

To assess DR among caregivers of children with neurogenic bladder following reconstructive bladder surgery.

STUDY DESIGN

A questionnaire including a validated DR survey was distributed to English-speaking caregivers of children with neurogenic bladder who had undergone reconstructive bladder surgery at Children's Hospital Colorado. DR scores range from zero to 100, with higher numbers indicating higher regret. Wilcoxon rank sum test and Spearman correlation were performed to assess differences in DR scores by patient demographic factors or disease factors.

RESULTS

Forty-five of 210 English-speaking caregivers completed the DR survey. The median DR score was 5, with 40% of subjects reporting with a DR score of zero and 24% of subjects with a DR score of 30 or higher. Patient sex and Mitrofanoff leakage were found to be associated with DR, with caregivers of male patients reporting significantly higher DR. Surgical procedure did not have a statistically significant impact on DR scores.

DISCUSSION

Sparse existing data exploring DR among patients with neurogenic bladder suggest DR following reconstructive bladder surgery is low, with few identifiable predictors of regret. While the majority of caregivers in our study report little or no DR, one quarter of caregivers report moderate to high DR. The limitations of this study include small cohort size, low response rate, exclusion of non-English speaking patients, and the potential for recall bias due to the survey design of the study.

CONCLUSION

Caregiver DR following bladder reconstruction in children with neurogenic bladder is generally low, however a subset of caregivers reports significant DR. This study suggests that caregivers of male children may have higher DR, a finding that merits further investigation.

Navigating parental decision-making: Intersex surgeries in Italy

Decision-making dynamics in Italian paediatric care for Intersex and Variations of Sex Characteristics (VSC) involve a complex interplay between medical practices, parental perspectives, and socio-cultural factors. This article explores how medical professionals and parents make decisions amid cultural debates on gender, the body, and autonomy. It addresses aspects of why surgical intervention, with limited child involvement, is often seen as the 'only option' in the 'conservative' culture of Italy. The article continues to highlight the rise of parent-led human rights-based activism in Italy, challenging prevailing narratives in intersex/VSC paediatric care. Using qualitative data from two studies, including interviews with 15 Italian stakeholders and 38 Italian parents, as well as participant action research, the article provides insights into Italian medical and parental perspectives. The findings emphasize the need for nuanced support, education, and resources to empower parents in order to uphold the rights and well-being of intersex individuals.

The Mediating Effect of Perceived Social Support and Health Literacy on the Relationship Between Decisional Dilemma and Participation in Shared Decision-Making Among Chinese Parents of Premature Infants

PURPOSE

This research was conducted to explore the mediating effect of perceived social support and health literacy on the relationship between decisional dilemmas and participation in shared decision-making among Chinese parents of premature infants.

DESIGN AND METHODS

This cross-sectional study recruited 225 Chinese parents of premature infants in a neonatal ward of a Chinese hospital through convenience sampling. Data were collected from August 2022 to February 2023 using 5 self-administered instruments. Structural equation modeling and multiple mediation tests were applied to explore the interplay among perceived social support, health literacy, decisional dilemmas, and participation in shared decision-making. The study is reported in accordance with the Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) guidelines.

RESULTS

Decisional dilemmas were found to negatively impact participation in shared decision-making. Perceived social support and health literacy were identified as partial mediators in this relationship, collectively accounting for a mediation effect of -0.413, which represents 50.0% of the total effect.

CONCLUSION

The findings elucidate a multifaceted model of factors influencing participation in shared decision-making among Chinese parents of premature infants. Prompt recognition of these variables can enable nursing professionals to incorporate tailored management strategies within patient-centered care frameworks, thereby enhancing decisional outcomes.

Parental regret following decision for sons to undergo elective post-neonatal circumcision

INTRODUCTION

The reasons for performing a circumcision among males after the neonatal period are usually cultural or medical. We aimed to evaluate parental regret for providing consent and to identify factors associated with such regret.

METHODS

Included were the parents of males aged 6 months to 18 years who underwent circumcision under general anesthesia at a single center between 2/2017 and 01/2023. Those who underwent additional surgical procedures during the same session were excluded. Parents responded telephonically to the Decision Regret Scale (DRS) questionnaire. Regret was classified as none (0 points), mild (1-25) or moderate-to-strong (26-100). Surgical and demographic data were retrieved for comparison to DRS scores and identification of predictors of parental regret.

RESULTS

In total, 201 of the 265 suitable patients met the inclusion criteria. Parents of 130 patients (65% response rate) whose average age was 5.06 (IQR 1.58,7.53) years completed the DRS questionnaire (study group). The average time since surgery was 41.8 (IQR 25.4,59.3) months. Forty surgeries were undertaken for cultural reasons and 90 for medical considerations. Eighteen parents reported regret (15 mild and 3 moderate-to-strong) for their decision to consent to their son's circumcision. The time from responding since surgery was the only significant variable in the DRS scores, with a 33-month gap predicting no regret (p = 0.02 compared to shorter gaps). The reasons for circumcision did not significantly differ between the "regret" and "no-regret" groups (p = 0.23).

DISCUSSION

Our current investigation revealed a lower incidence of parental regret when compared to previous reports following distal hypospadias repair, likely attributable to the lower complication rate associated with circumcision. Our data reflect the experience of a single center in a country where neonatal male circumcision is routinely performed for cultural and religious reasons, thus precluding the generalization of our findings to places where post-natal circumcision is less commonplace.

CONCLUSION

Consent to their son's post-neonatal circumcision was regretted by 13.8% of parents. Time since surgery significantly influenced the reduction of their negative attitudes.

Parental decision regret after pediatric urologic surgeries compared to decisions of everyday life

INTRODUCTION

Parents are at risk of decision regret (DR) for decisions affecting their children. The Decision Regret Scale (DRS) measures medical DR but lacks context outside of healthcare.

OBJECTIVE

To compare parental DR 1) between common pediatric urologic surgeries and everyday decisions and 2) with preference to make a different choice.

METHODS

We conducted a cross-sectional online survey of randomly selected parents >1year (y) after their children underwent: orchiopexy (males ≤10y), open ureteral reimplant (OUR, females 2-6y), open pyeloplasty (OP, ≤2y), or robotic pyeloplasty (RP, 5-17y) (2017-2021). Higher DRS scores indicate increased DR (none: 0, mild: 1-25, moderate: 30-50, strong: 55-75, very strong: 80-100). Parents completed DRS on four decisions: their child's surgery, most recent/current romantic relationship, most recent leased/purchased car, and most recent purchased meal. Parents reported if they would make the same choice (yes/no). Nonparametric statistics were used.

RESULTS

We surveyed 191 parents (orchiopexy n = 52, OUR n = 50, OP n = 51, RP n = 38). The median parent age was 36y (mothers: 86%). Some DR was reported for all decisions, but with significant differences in DR severity. The lowest median DRS score was seen with surgery (orchiopexy 0 [IQR 0-10], OUR 0 [IQR 0-5], OP 0 [IQR 0-0], RP 0 [IQR 0-0]), with no difference between surgery groups (p = 0.78). This was followed by relationship (0, IQR 0-20), car (15, IQR 0-25), and meal (20, IQR 0-30, p < 0.001). Most parents did not report any DR regarding surgery (orchiopexy 69%, OUR 74%, OP 76%, RP 76%, with no difference between surgery groups p = 0.85, Summary Figure). Comparatively, 59% of parents did not have any regret about their relationship, 37% their car, and 28% their meal (p < 0.001). All surgical DR was mild or moderate. No parent (0%) would have chosen differently for their child's surgery versus 4-12% for non-surgical decisions (p < 0.001). Overall, increasing DR corresponded to increasing desire to have made a different choice (DRS≤10: 0%, DRS 45-50: 32%, DRS 55-60: 66%, DRS≥75: 100%, p < 0.001).

CONCLUSION

Parental DR varied between urological surgical and non-surgical decisions. It was lowest after surgery. Some regret was reported after every decision, but the subset of parents with regret was smallest after surgical decisions. Positive DRS scores do not necessarily correspond to parents wishing they made a different choice.

Long-term outcomes of foreskin reconstruction in distal hypospadias; a cohort study spanning twenty years

INTRODUCTION

Surgical correction of hypospadias aims to achieve normal functionality and appearance. This entails foreskin reconstruction (FR) in countries where the uncircumcised penis constitutes the norm. Long-term data are however scarce.

OBJECTIVE

To investigate the long-term outcome of FR in cohort of patients operated for distal hypospadias combined with approximately 20 years after surgery.

METHODS

The hospital management system was searched for patients operated for distal hypospadias in conjunction with FR between 1997 and 2004. Prospective participants were invited to participate in an online questionnaire. Signed consent allowed for extended medical chart review, with regards to hypospadias grade, surgical procedure and complications.

RESULTS

Response rate of 44.6 %. For 113 participants, median age at primary surgery was 5.2 (1.0-15.5) years. Two-thirds had a distal meatus while the remaining, meatus was mid to distal shaft. Urethroplasties performed were mainly glanular approximation procedures and meatal based flap procedures in 85 %. Foreskin fistula developed in 15 % of cases. There was no significant relationship between urethroplasty procedure or meatal position and risk of foreskin complications. Three layer closure of foreskin resulted in significantly less complications than two layer closure. Twenty years on 95 % of the men still had an intact foreskin, of whom 16.8 % had received treatment for phimosis. Foreskin was retractable in 92.5 % and 74.7 % in the flaccid and erect states respectively. Ninety intact men had had their sexual debut and in those 23.3 % reported foreskin related issues with intercourse. Evolution of foreskin retractability can be seen in the figure.

DISCUSSION

Current results show that three layer FR in conjunction with hypospadias surgery is feasible and that short-term complication rates were comparable with what has previously been published in the literature. Long-term results indicate that FR is durable with regards to anatomical reconstruction however foreskin function especially in relation to sexual function was compromised in about 25 %. Foreskin retractability after surgery predicted retractability in adulthood for the flaccid but not erect penis. Limitations of this study include the retrospective nature of data collection, and that the questionnaire used was not validated. We however achieved a decent response rate and were able to capture important long-term data.

CONCLUSIONS

FR has an acceptable complication rate. Long-term results two decades on are remarkably durable with regards to the anatomical preservation of the prepuce, however functionality was compromised with regards to retractability and sexual function in approximately 25 %.

Should we correct hypospadias during childhood? Decision Regret And QUality of Life Assessment (DRAQULA) study

AIM OF THE WORK

To evaluate patient's satisfaction, Decision Regret And QUality of Life Assessment (DRAQULA) among adolescents (older than 15 years) and adults after hypospadias surgery in childhood.

PATIENTS AND METHODS

234 Patients operated on hypospadias as children in our center and their parents were contacted after they reached the age of 15 years to complete a questionnaire survey to assess satisfaction with the operative result, the regret with the operative decision and the health related quality of life (HRQOL). The survey is based on the Decision Regret Scale available in the literature with a score of 100 meaning maximum dissatisfaction or regret, and on the Kidscreen10 index. Satisfaction was measured on a scale from 1 to 5 with 5 signifying full satisfaction.

RESULTS

81 of 234 patients from 15 to 43 years (mean age 19.7 years) completed the survey (34.6 %). 44 Patients had distal, and 17 proximal hypospadias and the remaining 20 patients could not remember the type of hypospadias they had. The patient's satisfaction with the operative result was 5 (full satisfaction) in 74.1 %, 4 in 18.5 %, 3 in 6.2 % and 2 in 1.2 % (mean satisfaction score 4.7 of 5). Regarding decision regret among patients, 64/81 patients (79.0 %) had no decision regret. Only 14.8 % reported mild and 6.2 % moderate decisional regret (mean decisional regret score 4.8). 71 of 234 parents answered the parents' questionnaire (30.0 %). Fifty-eight (81.7 %) had no decision regret. 13 parents (18.3 %) had decision regret; 10 parents (14.1 %) reported mild, 2 parents (2.8 %) moderate, and only one parent (1.4 %) reported strong decisional regret. The mean HRQOL T-score was 55.9 (SD 10, control Group of adolescent males from 12 to 18 years.) and thus corresponded to the average of the reference normal population.

DISCUSSION

In this study, only 19.7 % had decision regret as compared to 50-65 % reported in literature. The decision regret scale of O'Connor needs to be revalidated as even candidates who approve of the decision of early surgery have a score less than 25 and considered to have decision regret.

CONCLUSION

The results of the survey showed that 90 % of the patients were satisfied with early hypospadias surgery with average HRQOL and low level of decisional regret in patients as well as parents. The findings support the current practice of operating hypospadias in early childhood.

Decisional conflict in American parents regarding newborn circumcision

BACKGROUND

Decisional conflict surrounding the topic of circumcision in the newborn male is assumed in some parents but has not been quantified or qualified. It is known that parents often base their decision on cultural and social factors and that physician discussions do affect ultimate decision-making. Information on parents' decision-making surrounding newborn circumcision and ways to mitigate conflict or uncertainty around the decision-making process is needed to better counsel them appropriately.

OBJECTIVES

To identify the presence or absence of decisional conflict in parents-to-be deciding whether or not to circumcise their child as well as to identify determinants of this conflict to direct future educational measures.

STUDY DESIGN

Parents presenting to obstetrics clinic as well as contacted by institutional email were recruited using convenience sampling and completed the validated Decisional Conflict Scale (DCS). A smaller subset of subjects were recruited via institutional email to complete semi-structured interviews regarding the decision-making process and specifically uncertainty regarding the decision. Descriptive statistics and unpaired t tests were used for analysis of survey data. For interview data, an iterative, grounded theory methodology was used.

RESULTS

173 subjects completed the DCS. 12% of all participants had high decisional conflict. Intuitively, those who had not yet decided whether to circumcise had the highest proportion of high DCS (69%), followed by those who had decided to circumcise (9.3%) and those who had decided not to circumcise (1.7%). 24 subjects were interviewed, and based on their DCS scores and interview responses were classified as low, intermediate and high conflict. Three primary themes emerged delineating the high from low conflict groups. There were notable differences in the feelings of subjects regarding knowledge and feeling informed, the importance of particular values and clarity of the roles of these values in decision-making, and feelings of supported decision-making. These themes were used to create a visual model depicting the individual needs of each decision-maker (Fig. 1).

DISCUSSION

This study highlights the need for decision support for parents that is not only information-based but focuses on values clarity and supported decision-making. This study provides a jumping-off point for creation of shared decision-making tools directed at individual needs. The limitations of this study are a single institution design and homogeneous population, so when designing materials, additional unrecognized needs will likely be identified.

CONCLUSION

A small, but real proportion of parents-to-be experience significant uncertainty around the decision to circumcise their newborn boys. Identified needs of parents include feeling informed, feeling supported and clarification of important values related to the problem.

Perception of Treatment Success and Impact on Function with Antibiotics or Appendectomy for Appendicitis: A Randomized Clinical Trial with an Observational Cohort

OBJECTIVE

To compare secondary patient reported outcomes of perceptions of treatment success and function for patients treated for appendicitis with appendectomy vs. antibiotics at 30 days.

SUMMARY BACKGROUND DATA

The Comparison of Outcomes of antibiotic Drugs and Appendectomy trial found antibiotics noninferior to appendectomy based on 30-day health status. To address questions about outcomes among participants with lower socioeconomic status, we explored the relationship of sociodemographic and clinical factors and outcomes.

METHODS

We focused on 4 patient reported outcomes at 30 days: high decisional regret, dissatisfaction with treatment, problems performing usual activities, and missing >10 days of work. The randomized (RCT) and observational cohorts were pooled for exploration of baseline factors. The RCT cohort alone was used for comparison of treatments. Logistic regression was used to assess associations.

RESULTS

The pooled cohort contained 2062 participants; 1552 from the RCT. Overall, regret and dissatisfaction were low whereas problems with usual activities and prolonged missed work occurred more frequently. In the RCT, those assigned to antibiotics had more regret (Odd ratios (OR) 2.97, 95% Confidence intervals (CI) 2.05-4.31) and dissatisfaction (OR 1.98, 95%CI 1.25-3.12), and reported less missed work (OR 0.39, 95%CI 0.27-0.56). Factors associated with function outcomes included sociodemographic and clinical variables for both treatment arms. Fewer factors were associated with dissatisfaction and regret.

CONCLUSIONS

Overall, participants reported high satisfaction, low regret, and were frequently able to resume usual activities and return to work. When comparing treatments for appendicitis, no single measure defines success or failure for all people. The reported data may inform discussions regarding the most appropriate treatment for individuals.

TRIAL REGISTRATION

Clinicaltrials.gov Identifier: NCT02800785.

Decisional Regret Among Caregivers of Infants with Differences of Sex Development Reared as Male

OBJECTIVE

Differences of sex development (DSD) are congenital conditions in which individuals are discordant in their chromosomal, phenotypic, and/or gonadal sex. Treatment of DSD can involve surgical intervention to external genitalia to make anatomy seem male-typical (i.e., male genitoplasty). Caregiver-perceived decisional regret regarding young boys with DSD was explored quantitatively and qualitatively.

METHOD

Participants (N = 39) were caregivers of infants (N = 23) diagnosed with DSD (mean age = 8.9 months, standard deviation = 5.9 months) reared male participating in a longitudinal investigation of psychosocial outcomes. Qualitative data were collected at 6 to 12 months after baseline enrollment to evaluate caregiver decision-making corresponding to levels of regret concerning their child's treatment. All but one infant received genital surgery before caregiver reporting on their decisional regret. Quantitative exploratory analyses evaluated longitudinal predictors of decisional regret at 6 to 12 months.

RESULTS

When completing a write-in item inquiring about decision-making and potential regret, most caregivers (n = 16, 76%) reported that their child's genital surgery was their first medical decision. Two caregivers referenced gender assignment as a decision point. One-third of caregivers reported some level of decisional regret (33%), with 67% reporting no regret. No hypothesized predictors of decisional regret were statistically significant.

CONCLUSION

Many caregivers of infants with DSD reared male view genital surgery as a first health care decision. Approximately one-third of caregivers reported some level of decisional regret. Further research is warranted to explore long-term decisional regret; it will be particularly important to investigate the decisional regret of patients with DSD.

Decisional Support Needed when Facing Tough Decisions: Survey of Parents with Children having Differences of Sex Development

Introduction

Parents of infants and young children newly diagnosed with differences of sex development (DSD) commonly face medical and psychosocial management decisions at a time when they are first learning about the condition and cannot consult their child for input. The aim of this study was to identify areas of greatest need for parental decisional support.

Methods

34 parents of children receiving care for DSD at one of three US children's hospitals participated in a survey to learn what clinical and psychosocial decisions needed to be made on behalf of their child. Parents were then asked to identify and focus on a "tough" decision and respond to questions assessing factors affecting decision-making, decision-making preferences, decisional conflict, and decision regret. Descriptive analyses were conducted.

Results

Decisions about surgery and aspects of sharing information about their child's condition with others were the two most frequently reported decisions overall, experienced by 97% and 88% of parents, as well as most frequently nominated as tough decisions. Many parents reported mild to moderate levels of decisional conflict (59%) and decision regret (74%). Almost all parents (94%) reported experiencing at least one factor as interfering with decision-making (e.g., "worried too much about choosing the 'wrong' option"). Parents universally reported a desire to be involved in decision-making - preferably making the final decision primarily on their own (79%), or together with their child's healthcare providers (21%). The majority of parents judged healthcare providers (82%) and patient/family organizations (58%) as trustworthy sources of information.

Discussion

Parents of children with DSD encounter medical, surgical, and psychosocial management decisions. Despite difficulties including emotional distress and informational concerns (including gaps and overload), parents express strong desires to play key roles in decision-making on behalf of their children. Healthcare providers can help identify family-specific needs through observation and inquiry in the clinical context. Together with families, providers should focus on specific clinical management decisions and support parental involvement in making decisions on behalf of young children with DSD.

Hypospadias surgery: understanding parental emotions, decisions and regrets

This paper builds an argument about genital surgery in the context of medical treatment of children and young people with variations in sex characteristics. First, I set out what is known from existing research including psychological research, surgical follow-up studies and parental regret studies. Second, I present an analysis of surgeons' talk about children, young people and parents in relation to genital surgery. This paper focuses most specifically on hypospadias surgery, but the argumentation is relevant for other kinds of genital surgery carried out in the context of genital variations. The questions guiding this paper are: what research evidence supports hypospadias surgery and what research evidence brings this surgery into question? How might a new interpretation of the evidence, in light of psychosocial research and human rights concerns, contribute to a new perspective on elective genital surgery on minors with variations in sex characteristics? I draw out implications for clinicians supporting parents to decide whether a surgical pathway is the best option for their child.

Reviewing next of kin regrets in surgical decision-making: cross-sectional analysis of systematically searched literature

BACKGROUND

Decision-making concerning relatives undergoing surgery is challenging. It remains unclear to what extent implicated next of kin eventually regret their decisions and how this regret is assessed. Our aim was to systematically review the literature on decisional regret of next of kin and to describe the assessment tools used and the surgical populations studied.

METHODS

We included interventional or observational, quantitative or qualitative studies reporting the measurement of decisional regret of next of kin concerning relatives undergoing surgery. We searched a variety of databases without restriction on publication year. We assessed the quality of reporting of quantitative studies using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies and of qualitative studies using the Critical Appraisal Skills Program Checklist.

RESULTS

Thirteen cross-sectional, five prospective cohorts and five qualitative studies matched our inclusion criteria. In 18 studies (78%), patients were children, in five (22%), young or middle-aged adults. No study included elderly or frail patients. Thirteen studies (57%) used the original Decision Regret Scale which was validated for patients, but not for next of kin. Only 3 of the 18 (17%) quantitative studies and only one of the 4 (25%) qualitative studies were rated as "good" in the quality assessment.

CONCLUSION

None of the retrieved studies used validated tools to assess the decisional regret of next of kin and none of them examined this issue in elderly or frail surgical patients.

"Your child needs surgery": A survey-based evaluation of simulated expert consent conversations by key stakeholders

BACKGROUND

Consent conversations in pediatric surgery are essential components of pre-operative care which, when inadequate, can lead to significant adverse consequences for the child, parents, surgeon, and others in the healthcare system. The aim of this study is to explore expert consenting practice from the key stakeholders' perspective.

METHODS

Four senior attending pediatric surgeons obtained consent from a standardized mother of a child requiring surgery in two scenarios: a low-risk elective surgery (inguinal hernia repair - Video 1), and a high-risk emergency surgery (intestinal atresia - Video 2). All sessions were recorded. Families of children who had undergone minor or major surgery, families without medical or surgical background, and healthcare professionals were invited to view and evaluate the videos using a semi-structured questionnaire.

RESULTS

Out of 251 distributed surveys, 56 complete responses were received. Thirty two participants (57.1%) evaluated video 1 and 24 (42.9%) evaluated. Overall, 22 (69%) respondents to video 1 and 20 (84%) respondents to video 2 were "very satisfied" with the recorded consent conversation. Qualitative responses shared common themes of valuing surgeon empathy, good surgeon communication, patient engagement, and adequate time and information. Suggestions for improvement included additional resources and visual aids, improved patient engagement, and discussion of post-operative expectations.

CONCLUSION

Our data identifies strengths and gaps in the current consent process from the perspective of patient families and providers. Identified areas for improvement in the informed consent process based on multi-stakeholder input will guide the planned development of a consenting educational video resource.

LEVEL OF EVIDENCE

IV.

Family risk communication preferences in pediatric surgery: A scoping review

BACKGROUND

Effective patient-surgeon communication is vital in pediatric surgical practice. However, family (including child) preferences for the format and content of risk communication information are largely unknown. In order to optimize the shared-decision making process, this scoping review explored the family-preferred methods for risk communication in pediatric surgery.

METHODS

A search was conducted in 7 databases from inception until June 2020 to identify family risk communication preferences in pediatric surgical patients, with language restricted to English and French. Two independent reviewers completed the screening in Rayyan software following PRISMA protocol. Included publications were reviewed for data extraction, analyzed, and assessed for risk of bias using standardized instruments.

RESULTS

A total of 6370 publications were retrieved, out of which 70 were included. Studies were predominantly from ENT (30.0%), general surgery (15.7%), and urology (11.4%). Family-preferred risk communication methods were classified as visual, verbal, technology-based, written, decision aids or other. Technological (32.4%) and written tools (29.7%) were most commonly chosen by families as their preferred risk communication methods. Written tools were frequently used in general surgery and urology, while technology-based tools were widely used in ENT. Most studies were cross-sectional and had a significant risk of bias.

CONCLUSION

Eliciting families' preferences for risk communication methods is critical for the implementation of shared decision-making. Different risk communication media appear to be preferred within specific surgical domains. To further improve shared-decision making in pediatric surgery, the development and usage of robust, validated risk communication tools are necessary.

LEVEL OF EVIDENCE

Level IV (Scoping Review).

Being born small for gestational age (SGA) might be associated with a higher reoperation rate in proximal hypospadias

PURPOSE

Being born small for gestational age (SGA) is associated with a higher frequency and more severe forms of hypospadias as well as with potential developmental differences. This study aims to characterize operative outcomes in SGA boys compared to boys born with normal weight and length for gestational age (appropriate/large for gestational age, AGA/LGA).

METHODS

Demographic data, hypospadias characteristics, associated pathologies and operative outcomes of boys who underwent hypospadias repair at a single center (10/2012-10/2019) were evaluated. Boys were categorized into SGA and non-SGA, which were then compared using unpaired t-tests and chi square tests. To examine the effect of SGA on reoperative risk, a logistic regression model was applied integrating surgical technique, meatal localization and complex hypospadias (narrow glans/plate, curvature, micropenis, bilateral cryptorchidism).

RESULTS

SGA boys accounted for 13.7% (n = 80) of the total cohort (n = 584) and 33% of all proximal hypospadias (n = 99, SGA vs. non-SGA 41.3% vs. 13%, p < 0.001). After a mean follow-up of 18.6 months the reoperation rate for all hypospadias was 17.9% (n = 105). In distal hypospadias there was no difference in reoperation rate between SGA and AGA/LGA boys (p = 0.548, multivariate regression model). For each meatal localization in proximal hypospadias SGA was a significant, independent factor predicting higher reoperation rates (p = 0.019, OR 3.21) in a logistic regression model (Figure ROC).

DISCUSSION

Hypospadias surgery carries a substantial risk for unplanned reinterventions. Apart from meatal localization, there are only a few factors (urethral plate quality, glandular diameter, curvature) reported in literature to be associated with reoperative risk. Intrauterine growth retardation associated with SGA might lead to not only a higher probability of proximal hypospadias but also contribute to a higher risk for complications mediated by developmental differences. Whether these findings could help to tailor surgical strategies or adjuvant measures, as for example the application of preoperative hormonal stimulation remains to be determined in future studies. This study is limited by being a single-center series with limited follow-up resulting in some complications probably not yet detected - however, in the same extent in both groups.

CONCLUSION

Based on this study, 33% of all proximal hypospadias cases occur in boys born SGA. While the reoperation rate in boys with distal hypospadias was not influenced by SGA status, SGA proved to be an independent predictor of a higher risk of reoperation in those with proximal hypospadias. After validation of these findings in other centers, this could be integrated into counseling and risk-stratification.

Parental decision regret among Australian parents after consenting to or refusing hypospadias repair for their son: Results of a survey with controls

INTRODUCTION

Parental decision regret in hypospadias surgery is a recognised source of long-lasting psycho-social morbidity. High parental decision regret after their child's hypospadias repair is reported. The aim of this study is to report on decision regret in Australian parents, who accepted and declined surgery for their son and explore underlying factors for decision-making, satisfaction, and regret.

MATERIALS AND METHODS

An online anonymous survey was administered to three groups of parents: 1) parents who consented for hypospadias repair, 2) parents who declined repair and 3) a control group who requested circumcision for their child. Operations occurred between 2010 and 2020 in two paediatric hospitals in New South Wales, Australia. The survey included a validated decision regret assessment tool and additional questions to explore the possible basis of the opinions.

RESULTS

One hundred and eighteen parents (invited - 381, completed - 116, response rate - 31%) participated in the survey. Decision regret was present in group 1 (n = 89) - 55% (moderate-to-severe 15%), in group 2 (n = 14) - 71% (moderate-to-severe 57%), and in the control group (n = 15) - 15% (moderate-to-severe 8%) of parents. There was a significant difference in the median decision regret score between all three groups. Parents who chose hypospadias repair were mostly concerned about function.

CONCLUSIONS

The prevalence of decision regret among Australian parents who consented for their son's hypospadias repair was lower compared with the mean decision regret reported in the literature to date (55% vs 65%). Decision regret and its severity were highest among parents who declined hypospadias repair. New strategies are needed to reduce decision regret in parents whether they elect for surgery or not.

Diagnosis of DSD in Children—Development of New Tools for a Structured Diagnostic and Information Management Program within the Empower-DSD Study

Background: Current recommendations define a structured diagnostic process, transparent information, and psychosocial support by a specialized, multi-professional team as central in the care for children and adolescents with genital variations and a suspected difference of sex development (DSD). The active involvement of the child and their parents in shared decision-making should result in an individualized care plan. So far, this process has not been standardized. Methods: Within the Empower-DSD study, a team of professionals and representatives of patient advocacy groups developed a new diagnostic and information management program based on current recommendations and existing patient information. Results: The information management defines and standardizes generic care elements for the first weeks after a suspected DSD diagnosis. Three different tools were developed: a guideline for the specialized multiprofessional team, a personal health record and information kit for the child with DSD and their family, and a booklet for medical staff not specialized in DSD. Conclusions: The new information management offers guidance for patients and professionals during the first weeks after a DSD diagnosis is suspected. The developed tools’ evaluation will provide further insight into the diagnostic and information-sharing process as well as into all of the involved stakeholders’ needs.

Predictors of Decision Regret among Caregivers of Older Canadians Receiving Home Care: A Cross-Sectional Online Survey

Background. In Canada, caregivers of older adults receiving home care face difficult decisions that may lead to decision regret. We assessed difficult decisions and decision regret among caregivers of older adults receiving home care services and factors associated with decision regret. Methods. From March 13 to 30, 2020, at the outbreak of the COVID-19 pandemic, we conducted an online survey with caregivers of older adults receiving home care in the 10 Canadian provinces. We distributed a self-administered questionnaire through Canada’s largest and most representative private online panel. We identified types of difficult health-related decisions faced in the past year and their frequency and evaluated decision regret using the Decision Regret Scale (DRS), scored from 0 to 100. We performed descriptive statistics as well as bivariable and multivariable linear regression to identify factors predicting decision regret. Results. Among 932 participants, the mean age was 42.2 y (SD = 15.6 y), and 58.4% were male. The most frequently reported difficult decisions were regarding housing and safety (75.1%). The mean DRS score was 28.8/100 (SD = 8.6). Factors associated with less decision regret included higher caregiver age, involvement of other family members in the decision-making process, wanting to receive information about the options, and considering organizations interested in the decision topic and health care professionals as trustworthy sources of information (all P < 0.001). Factors associated with more decision regret included mismatch between the caregiver’s preferred option and the decision made, the involvement of spouses in the decision-making process, higher decisional conflict, and higher burden of care (all P < 0.001). Discussion. Decisions about housing and safety were the difficult decisions most frequently encountered by caregivers of older adults in this survey. Our results will inform future decision support interventions.

Correlation Between Intolerance of Uncertainty and Post-Operative Regret in Otolaryngology Patients

OBJECTIVE

To determine if intolerance of uncertainty, depression, anxiety, worry, or stress are related to post-op regret in otolaryngology patients.

METHODS

Adult patients or parents giving consent for pediatric patients meeting criteria for otolaryngologic surgery were recruited and completed the Intolerance of Uncertainty Scale (IUS-12), Penn State Worry Questionnaire (PSWQ), and Depression, Anxiety and Stress Scale-21 (DASS-21) preop and the Decisional Regret (DR) scale 1-month post-op. Pearson correlations were calculated.

RESULTS

The cohort included 109 patients, 73 (67%) males and 36 (33.3%) females. 43 (39.5%) were college graduates and 66 (60.9%) were not. Mean IUS-12 score was 22.9 (95% CI 21.0-24.8), mean PSWQ score was 46.9 (95% CI 44.5-49.3). DASS-21 mean score was 11.9 (95% CI 9.6-14.3). Mean DR score was 11.1 (95% CI 8.6-13.6). IUS-12 subscales Prospective Anxiety mean score was 14.2 (95% CI 12.8-15.5) and Inhibitory Anxiety mean score was 16.5 (95% CI 14.5-18.6). The Pearson correlation coefficient for post-op DR and total preop IUS was .188 (P = .027) and the correlation coefficient for post-op DR and preop Prospective Anxiety subscale of IUS score was .174 (P = .037). Correlations with PSWQ and DASS-21 scores and DR were not statistically significant.

CONCLUSION

Intolerance of uncertainty is a psychological construct that is associated with post-op DR. More work is needed to determine whether screening for IU and behavior modification directed at IU for those with high levels would improve post-op decisional regret.

Decisional Satisfaction, Regret, and Conflict Among Parents of Infants with Neurologic Conditions

OBJECTIVE

To characterize decisional satisfaction, regret, and conflict among parents of critically ill infants with neurologic conditions.

STUDY DESIGN

In this prospective cohort study, we enrolled parents of infants with neurologic conditions in the intensive care unit (ICU). Hospital discharge surveys included the validated Family Satisfaction with the ICU (FS-ICU) decision making subscale, Decision Regret Scale (DRS), and Decisional Conflict Scale (DCS). We defined high satisfaction with decision making as an FS-ICU score ≥75, high decisional regret/conflict as DRS/DCS score >25, and within-couple disagreement as a difference of at least 25 points between scores.

RESULTS

We enrolled 61 parents of 40 infants (n = 40 mothers, n = 21 fathers); 35 mothers and 15 fathers completed surveys. Most mothers reported high satisfaction with decision making (27 of 35; 77%) and low decision regret (28 of 35; 80%); 40% (14 of 35) reported high decisional conflict. Mothers and fathers reported higher decisional conflict in the domains of uncertainty and values clarity compared with the domain of effective decision making (Bonferroni-corrected P < .05). There were no differences in decision outcomes between paired mothers and fathers; however, within any given couple, there were numerous instances of disagreement (7 of 15 for decision regret and 5 of 15 for decisional conflict).

CONCLUSIONS

Many parents experience decisional conflict even if they ultimately have high satisfaction and low regret, underscoring the need for decision aids targeting uncertainty and values clarity. Couples frequently experience different levels of decisional regret and conflict.

Intersexuality/Differences of Sex Development through the Discourse of Intersex People, Their Relatives, and Health Experts: A Descriptive Qualitative Study

Intersex/differences of sex development (DSD) conditions are divergences among genitalia, gonads, and chromosome patterns. These variances have been present for millennia and socially defined according to the cultural system established. The aim of this study is to describe the perspectives of adult intersex/DSD people, their relatives, and intersex/DSD expert professionals in Spain. A descriptive qualitative study design was adopted. The study was carried out in several locations in Spain. Individual in-depth interviews were conducted and addressed to 12 participants (4 intersex/DSD people, 3 relatives, and 5 professional experts). A total of 4 spheres, 10 categories, and 26 subcategories were obtained. The number of verbatims obtained in each of the spheres described were intersex/DSD as a community (n = 54), health sphere approach (n = 77), law sphere approach (n = 12), and psychosocial approach (n = 73). Regarding intersex/DSD as a community sphere, there is a clear need of promoting education on sex and body diversity. With respect to the health sphere, it is mentioned the inadequacy of services and how this has a negative impact on the health of intersex/DSD people. Regarding the law sphere, it is highlighted the need of designing legislations at a national level which protect and defend the rights of intersex/DSD people. Regarding the psychosocial sphere, these people suffer from social isolation, secrecy, shame, self-identity questioning, and mental disorders that negatively impact their quality of life.

Ask the parents: Testing the acceptability and usability of a hypospadias decision aid

INTRODUCTION

In previous work, we engaged key stakeholders to create a web-based decision aid (DA) prototype to facilitate shared decision making about hypospadias.

OBJECTIVE

The study's objective was to use a human-centered design approach to assess the DA's acceptability and usability and revise it prior to pilot testing.

METHODS

We recruited English-speaking parents (≥18 years old) of sons with hypospadias (≤5 years) for a two-phase process of semi-structured phone/video interviews to obtain feedback about our DA prototype. DA webpages included: "Hypospadias," "Surgery Basics," "No Surgery," "Family Stories," "Help Me Decide," and "FAQs." In both phases, participants viewed the DA using the "think aloud" technique and completed several validated scales to evaluate its acceptability and usability. In phase 1, we collected feedback about the "Homepage" organization, values clarification methods (VCM), and webpage content. In phase 2, participants searched the DA for answers to hypospadias-related questions, provided feedback on testimonial videos and VCM, and shared their preferences about data visualizations. All interviews were audio recorded. After each phase, transcripts were qualitatively analyzed to identify key areas for revision. Revisions were made between phase 1 and 2 to improve the DA's acceptability and usability.

RESULTS

We interviewed 20 participants (10/phase): median age 33.7 years, 60% female, 80% White. Mean score on the Preparation for Decision Making Scale: 86.8 (out of 100). We revised: 1) VCM, focusing on pros/cons of surgery and question prompts, 2) "Homepage," adding webpage descriptions (Extended Summary Figure), 3) menu organization, 4) "Surgery Day" webpage, adding general anesthesia risk information, and 5) "Hypospadias" webpage, adding an icon bar graph to help participants visualize statistics. Participants thought the testimonial videos were relatable and the VCMs would prepare them for their visit with their child's urologist.

DISCUSSION

Ours is the first parent-centered DA developed and pre-tested for hypospadias. Using validated usability and acceptability scales, participants highly rated the DA in helping them arrive at a decision about surgery. Study limitations include the sample's lack of diversity (i.e., educated, health literate) and participants already decided about their son's hypospadias management before enrolling. To learn more about the DA's usability and acceptability, we plan to pilot test it in a clinical setting.

CONCLUSIONS

Participants found our DA informative in understanding hypospadias. There was a high perceived level of preparation for hypospadias decision making. Participatory research methods, such as "think aloud," may be helpful when testing DAs as they privilege the patient's experience.

Decisional regret about surgical and non-surgical issues after genitoplasty among caregivers of female infants with CAH

INTRODUCTION

Caregivers of female infants with congenital adrenal hyperplasia (CAH) often confront complex medical decision-making (e.g., early feminizing genitoplasty).

OBJECTIVE

This study aimed to evaluate the relevant medical decisions and subsequent decisional regret of caregivers following their child's genitoplasty.

STUDY DESIGN

Caregivers (N = 55) were recruited from multidisciplinary treatment programs for participation in a longitudinal study. Qualitative data was collected at 6-12 months following feminizing genitoplasty to evaluate caregiver-reported decision points across their child's treatment. Quantitative exploratory analysis evaluated pre-operative predictors of subsequent decisional regret.

DISCUSSION

When prompted about their decision-making and potential regret, most caregivers (n = 32, 80%) reported that their daughter's genital surgery was their primary medical decision. Specific themes regarding genital surgery included the timing and type of surgery. Most caregivers reported no decisional regret (62%), with 38% reporting some level of regret. Greater pre-operative illness uncertainty predicted heightened decisional regret at follow-up, p = .001.

CONCLUSION

Two-thirds of caregivers of female infants with CAH reported not regretting their decision-making. Nevertheless, over one-third of caregivers reported some level of regret, suggesting the need for improvements in shared decision-making processes. Many, but not all, families reported that this regret was related to surgical decision-making. Reducing caregiver illness uncertainty (e.g., providing clear information to families) may increase their satisfaction with decision-making. Further research is needed to determine how the evolving care practices surrounding early genitoplasty will impact families.

Parental Regret Following Decision to Revise Circumcision

PURPOSE

Revision surgery for the removal of excess foreskin after circumcision is a common procedure. The decision regret scale (DRS) is a validated questionnaire which assesses regret after medical decision making. The aim was to evaluate parental regret by means of the DRS and querying about factors associated with regret about deciding to revise their child's circumcision.

PATIENTS AND METHODS

Included were all pediatric patients who underwent revision of neonatal circumcision in a single center between 2010 and 2016. Excluded were children who underwent revision for reasons other than excess foreskin, those who underwent additional surgical procedures during the same anesthetic session, and those who had undergone previous penile surgery other than circumcision. Response to the DRS questionnaire was by a telephone call with the patient's parent. Regret was classified as none (a score of 0), mild (1-25), or moderate-to-strong (26-100). Surgical and baseline demographic data were obtained from the departmental database and compared between the no regret and regret groups.

RESULTS

Of the 115 revisions of circumcisions performed during the study period, 52 fulfilled the inclusion criteria, and the parents of 40 (77%) completed the DRS questionnaire. Regret was reported by 11/40 [28%: nine as mild (23%) and two as moderate-to-strong (5%)]. The average age of the child in the regret group was 17 months compared to 18 months in the no regret group (p = 0.27). The median weight percentile was 43% in both groups. Surgical variables, including anesthesia type (caudal vs. no block, p = 0.65), suture type (polyglactin vs. poliglecaprone, p = 0.29), operation time (28 vs. 25 min, p = 0.59), and anesthesia time (55 vs. 54 min, p = 0.57) were not significantly different between the groups.

CONCLUSIONS

Regret for deciding upon revision surgery for removal of excess foreskin post-circumcision was reported by 27.5% of parents of children who underwent revision. No clinical, surgical, or demographic characteristics predicted parental decisional regret.

Staged Buccal Mucosa Graft Urethroplasty for Proximal Hypospadias in Children: A Short- to Mid-Term Follow-Up Retrospective Study

INTRODUCTION

 The aim of this study is to report our experience with modified staged buccal mucosa graft urethroplasty for the repair of proximal hypospadias in children and adolescents.

MATERIALS AND METHODS

 A total of 183 patients were treated at the Plastic Surgery Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College between 2010 and 2019. The patients were grouped according to age: (1) within 1.5-year-old group, (2) prepuberty group (Tanner stage 1), and (3) puberty group.

RESULTS

 In total, 153 patients were included in this study. Thirty-six patients had complications: seven after stage one; 29 after stage two; one patient had two complications. Maximum flow rates were 11.80 ± 1.46 mL/s in the 1.5-year-old group, 13.24 ± 2.61 mL/s in the prepuberty group, and 13.60 ± 2.20 mL/s in the puberty group (p = 0.199). Average flow rates were 6.86 ± 1.37, 7.94 ± 1.74, and 7.88 ± 1.22 mL/s, respectively (p = 0.203). The optimal hypospadias objective scoring evaluation score of 16 was seen in 117 patients (76%), the score of 15 in 23 patients (15%), 14 in 10 (7%), and 13 in 3 patients (2%). Patients with an uncomplicated treatment (no complication) had a higher clinical outcome than patients with a complication (15.8 ± 0.53 vs. 15.3 ± 0.97, with or without complication, p = 0.000). Multivariable analyses showed that previous treatment was closely related to the complication rate (p = 0.016).

CONCLUSION

 The modified procedure allows for two-stage repair of proximal hypospadias with good results with a low complication rate and good functional results. Delaying operation did not increase complication rates in our research.

Parental decisional regret after surgical treatment in young boys born with hypospadias

BACKGROUND/PURPOSE

Parental decisional conflict and decisional regret are aspects in parental adjustment to childhood elective surgery. This study assessed correlates of parental decisional regret in parents of young boys treated for hypospadias.

METHODS

Parents of 261 boys treated for hypospadias at the Radboudumc between 2006 and 2014 were approached to complete questionnaires on socio-demographics, clinical details, postoperative outcomes, decisional conflict and decisional regret.

RESULTS

Of the 97 participating parents, 50.5% reported some form of decisional regret, in 11.3% this was moderate to strong. Decisional conflict (β = .68, p < .001) and psychosocial behavior problems of the child (β = .20, p < .05) significantly predicted decisional regret. Demographic and medical variables did not correlate with parental decisional regret.

CONCLUSIONS

A substantial number of parents report some form of decisional regret regarding the elective surgery for hypospadias in their child. Although most parents only show mild forms of regret, in the perspective of discussions on this surgery in early childhood, future research could shed more light on the interrelationship between medical and psychosocial factors in the process of decision-making around surgery, in boys with hypospadias and their parents.

Individualized care for patients with intersex (differences of sex development): part 4/5.Considering the Ifs, Whens, and Whats regarding sexual-reproductive system surgery

Issues and concerns regarding surgery of the sexual-reproductive anatomy during infancy and early childhood are discussed using four actual examples. A case of a 46, XX infant with 21 hydroxylase deficiency congenital adrenal hyperplasia (CAH) with atypical (ambiguous) genitalia is discussed regarding timing and potential harms and benefits of surgery. We present the perspective of balancing the child's rights to bodily autonomy and right to an open future versus parents' decision making authority regarding what they perceive as their child's future best interests. The second case is a newborn with complete androgen insensitivity syndrome and we discuss the harms, benefits and timing of gonadectomy. The third case examines the physical and psychological impact of penile shaft hypospadias, raising the question of whether surgery is justified to prevent what may or may not be considered a permanent disability. The fourth case involves an adult woman with classic CAH, born with a urogenital sinus and clitoromegaly, who never had genital surgery and is now requesting vaginoplasty, but not clitoral reduction. The primary message of this article, as the previous articles in this series, is to encourage patient-family centered care that individualizes treatment guided by shared decision making.

Decision aids for prenatal testing: A systematic review and meta-analysis

AIMS

To analyse the effect of decision aids (DAs) used by pregnant women on prenatal testing decisions.

DESIGN

Systematic review and meta-analysis.

DATA RESOURCES

We searched Embase, PubMed, Web of Science and the Cochrane Central Library ending October 2020.

REVIEW METHODS

Papers were selected for analysis in accordance with the PRISMA guidelines. The meta-analysis was carried out using Review Manager 5.3 software. The quality of the studies was assessed using the risk of bias tool recommended by the Cochrane Handbook. The result is knowledge, decision conflict, anxiety and other secondary outcomes.

RESULTS

A total of 18 studies were included in the systematic review and meta-analysis. Comprehensive analysis showed that DAs could significantly improve knowledge and decision-making satisfaction, reduce decision conflict, increase the proportion of women who make informed choice and had no influence on anxiety and decision regret.

CONCLUSIONS

This article systematically reviewed the positive effect of DAs on the decision-making of pregnant women facing prenatal testing. In the future, nurses should be encouraged to develop DAs in accordance with strict standards and apply them to pregnant women of different backgrounds.

IMPACT

There is a growing consensus that health care should be patient-centred, and the values and preferences of pregnant women who undergo prenatal testing need to be incorporated into the clinical decision-making process. This review reports that the use of DAs can increase pregnant women's chances of participating in prenatal testing decisions and may improve the quality of their decision-making. It also provides information on the role and practice of nurses in promoting evidence-based prenatal testing for DAs.

Parental Concerns of Boys with Hypospadias

Introduction

Reports indicate many parents are negatively impacted by their child’s birth defect, experiencing feelings of anxiety, shame, and blame. These reactions have been documented for several conditions, but not hypospadias. We surveyed parents of boys with hypospadias to determine their concerns.

Materials

The validated Impact of a Child with Congenital Anomalies on Parents (ICCAP) questionnaire was administered to parents recruited through social media.

Results

There were 260 respondents (80% female, average age 35 years): 86% said they had never heard of hypospadias before their son’s diagnosis; 57% of mothers and 38% of fathers wondered if they were to blame for the hypospadias. This increased to 78% among women given progesterone during pregnancy. Sixty-four percent reported they worry “a great deal” about their son’s health, despite successful repair, which increased to 88% when surgery was not successful. Twenty percent responded that the surgeon did not spend enough time with them.

Conclusion

Most parents of newborns with hypospadias have never previously heard of the condition. Many wondered if they are to blame for the birth defect, and most reported that they worry “a great deal” about their son’s future health, whether or not repair was successful. One in five said surgeons did not spend enough time to discuss these concerns, and one in four said their explanations were unclear. Awareness of these concerns is important for urologists since they are the primary caregivers for patients with hypospadias.

Repair of distal hypospadias by construction of neourethra from augmented urethral plate with two lateral strips of glans skin and coverage with dartos flap followed by skin closure with preputial flap: single center series

Introduction

Hypospadias is one of the most common anomalies in boys. Many surgical techniques for reconstruction of distal hypospadias have been described, each method having a different success rate. Our objective in this study is the assessment of the surgical technique for repair of distal hypospadias by construction of a neourethra from the augmented urethral plate with two lateral strips of glanular skin, coverage with a dartos flap, and followed by skin closure with preputial skin flap.

Material and methods

From March 2016 to November 2018, repair of distal hypospadias was performed in 56 children with a mean age of 3.2 years (range 2 to 8 years old). Minimum follow-up was 12 months, maximum up to 24 months. Success was defined by cosmetic appearance of the penis, parent perception of penile appearance, and urinary function. Uroflowmetry was done in 22 children at the 12 months follow-up. Parents evaluation of procedure was done by questionnaire using the pediatric penile perception score (PPPS).

Results

The results were successful with straight penile shaft, conical glans, slit-like meatus located at the tip of the glans, with no rotation, and normal micturition. Five children had urethrocutaneous fistula (8.9%) that were treated with simple closure. Parents reported 'very satisfactory' (98.2%) and 'satisfactory' (1.8%).

Conclusions

The described technique of repair of distal hypospadias in children with different variants of urethral plate width and glans size showed good results, both operator's and parent's perception of the results being very satisfactory. This technique is categorised stage 2a in the IDEAL (Idea, Development, Evaluation, Assessment, and Long-term study) staging system for surgical innovations.

Relationship Between Parental Intolerance of Uncertainty and Decisional Conflict in Pediatric Otolaryngologic Surgery

OBJECTIVE

To assess the relationship between depression, anxiety, stress, worry, intolerance of uncertainty (IU), and shared decision making (SDM) in parents of pediatric otolaryngology surgical patients with their perceptions of decisional conflict (DC).

STUDY DESIGN

Cross-sectional.

SETTING

Academic pediatric otolaryngology outpatient clinic.

METHODS

Participants were legal guardians of pediatric patients who met criteria for otolaryngologic surgery. Participants completed a demographic survey as well as validated Decisional Conflict Scale (DCS); Shared Decision-Making Scale (SDMS); Depression, Anxiety and Stress Scale-21 (DASS-21); Penn State Worry Questionnaire (PSWQ); and short form of the Intolerance of Uncertainty Scale (IUS-12).

RESULTS

A total of 114 participants were enrolled. Respondents were predominantly female (93.0%) and married (60.5%). Most guardians had not consented previously for otolaryngologic surgery for their child (69.3%). Participants reported low levels of DC and depression as well as moderate levels of anxiety and stress. DC scores were not significantly correlated to DASS-21, PSWQ, or SDM. IUS-12 Total and subscale IUS-12 prospective negatively correlated with Total DC. DC was not related to age, sex, education level, previous otolaryngologic surgery, or type of surgery recommended.

CONCLUSION

In this group, an association was found between IU and DC. Clinicians should be aware that DC is not modified by previous surgical experience. Interventions aimed at addressing parental IU related to surgery may reduce DC. Further research efforts could help us understand how mental health relates to surgical decision making.

Extent and Predictors of Decision Regret among Informal Caregivers Making Decisions for a Loved One: A Systematic Review

BACKGROUND

Informal caregivers often serve as decision makers for dependent or vulnerable individuals facing health care decisions. Decision regret is one of the most prevalent outcomes reported by informal caregivers who have made such decisions.

OBJECTIVE

To examine levels of decision regret and its predictors among informal caregivers who have made health-related decisions for a loved one.

DATA SOURCES

We performed a systematic search of Embase, MEDLINE, Web of Science, and Google Scholar up to November 2018. Participants were informal caregivers, and the outcome was decision regret as measured using the Decision Regret Scale (DRS).

REVIEW METHODS

Two reviewers independently selected eligible studies, extracted data, and assessed the methodological quality of studies using the Mixed Methods Appraisal Tool. We performed a narrative synthesis and presented predictors of decision regret using a conceptual framework, dividing the predictors into decision antecedents, decision-making process, and decision outcomes.

RESULTS

We included 16 of 3003 studies identified. Most studies (n = 13) reported a mean DRS score ranging from 7.0 to 32.3 out of 100 (median = 14.3). The methodological quality of studies was acceptable. We organized predictors and their estimated effects (β) or odds ratio (OR) with 95% confidence interval (CI) as follows: decision antecedents (e.g., caregivers' desire to avoid the decision, OR 2.07, 95% CI [1.04-4.12], P = 0.04), decision-making process (e.g., caregivers' perception of effective decision making, β = 0.49 [0.05, 0.93], P < 0.01), and decision outcomes (e.g., incontinence, OR = 4.4 [1.1, 18.1], P < 0.001).

CONCLUSIONS

This review shows that informal caregivers' level of decision regret is generally low but is high for some decisions. We also identified predictors of regret during different stages of the decision-making process. These findings may guide future research on improving caregivers' experiences.

Parental decision regret in childhood hypospadias surgery: A systematic review

We conducted a systematic review of the literature to establish the prevalence of and predictive factors for parental decision regret in hypospadias surgery. A search strategy without language restrictions was developed with expert help, and two reviewers undertook independent study selection. Five studies were included in this review (four for quantitative analysis) with a total of 783 participants. The mean overall prevalence of parental decision regret was 65.2% (moderate to severe - 20.3%). Although significant predictors of regret were identified (post-operative complications, small size glans, meatal location, decision conflict between parents, parental educational level and others), they had unexplained discordance between studies. Parental decision regret after proximal hypospadias surgery and refusing surgery was inadequately reported. In conclusion, even though the prevalence of parental decision regret after consenting for the hypospadias repair appears to be high, risk factors associated with it were discordant suggesting imprecision in estimates due to unknown confounders.

User testing of a hypospadias decision aid prototype at a pediatric medical conference

INTRODUCTION

Based on our previous qualitative work, we created a web-based decision aid (DA) prototype to facilitate shared decision-making regarding hypospadias.

OBJECTIVE

The objective of this study was to obtain rapid feedback on the prototype as part of an iterative, human-centered design process.

METHODS

We conducted this study at a statewide, pediatric educational conference in May 2019, recruiting attendees by verbal/written announcements. The DA consisted of: hypospadias overview and surgery "storyboard," frequently asked questions, parent testimonials, and a values clarification exercise. Participants viewed the DA on a tablet as they participated in semi-structured, qualitative interviews covering website acceptability, usability, and preference for surgical photographs versus illustrations. Three coders used qualitative content analysis to identify themes and resolved disagreements by consensus.

RESULTS

Of 295 conference attendees, all 50 who approached us agreed to participate. Responses from 49 participants were available for analysis: 67% female, ages 20-69, 65% Caucasian, 55% MDs. 96% of participants thought the website design matched its purpose; 59.1% preferred surgical illustrations, 8.2% preferred photos, 30.6% preferred both and 2.0% did not like either. Participants recommended improvements in: a) usability/accessibility (e.g. site navigation, visual layout, page length), b) content coverage (e.g. epidemiology, consequences of no/delayed surgery, lifelong risks), c) parent-centeredness (e.g. reading level/writing style) and d) implementation (provider tools, printable handouts). The Extended Summary Figure shows a revised image of the first step of a hypospadias repair based on feedback about participants' preferences for illustrations rather than photographs.

DISCUSSION

The main strength of our study was the valuable feedback we obtained to inform critical revisions of the DA prototype. We also demonstrated the feasibility and efficacy of a conducting a usability evaluation of a web-based DA in a medical conference setting. One limitation of this study is that the relatively small population sampled limits generalizability and our findings may not reflect the views of all providers who care for hypospadias patients.

CONCLUSIONS

The vast majority of providers thought that the design of the Hypospadias Homepage matched its purpose and most preferred surgical illustrations rather than photos to demonstrate the steps of hypospadias surgery. Based on their feedback, we plan to focus our efforts in the following areas: 1) improvement of navigation/menus, 2) reduction in the amount of text per page, 3) expansion of specific content coverage and 4) inclusion of "parent-friendly" visuals such as infographics to represent quantitative data and colorful illustrations to depict hypospadias and its surgical repair.

User-centered development of a hypospadias decision aid prototype

INTRODUCTION

Many parents who choose hypospadias repair for their sons experience decisional conflict (DC) and decisional regret (DR). We previously found that parental decision-making about hypospadias surgery is a complex process characterized by cyclic information-seeking to alleviate anxiety and confusion.

OBJECTIVE

The objective of this study was to engage parents of hypospadias patients and pediatric providers in the co-design of a decision aid (DA) prototype to facilitate shared decision-making about hypospadias surgery and address DC and DR.

METHODS

From August 2018 to January 2019, we conducted three co-design workshops with parents of hypospadias patients, pediatric urology and general pediatric providers to discuss their recommendations for a DA prototype. Activities were audio recorded and professionally transcribed. Transcripts and worksheets were analyzed by six coders using qualitative analysis to identify key aspects of a hypospadias DA desired by stakeholders. We conducted a collaborative design and prototyping session to establish key features and requirements, created a content map visualizing this work, and then developed a DA prototype.

RESULTS

Parent participants included 6 mothers and 4 fathers: 8 Caucasian, 2 African-American; median age 31 years. Providers included pediatric urology (n = 7) and general pediatric providers (n = 10): median age 47.5 years, 83.3% Caucasian, 58.3% male, 58.3% MD's and 41.7% nurse practitioners. Participants created user-friendly, interactive DA prototypes with "24/7" availability that had three key functions: 1) provide accurate, customizable, educational content, 2) connect parents with each other, and 3) engage them in a decision-making activity. The prototype consisted of five modules (Extended Summary Figure). "Hypospadias Basics" includes epidemiology and a hypospadias severity scale. "Surgery Basics" includes goals, illustrated steps, and pros/cons of surgery. "Testimonials" includes videos of parents and adolescents discussing their experiences. "Help me Decide" includes a decisional conflict scale and a decision-making activity (i.e. values clarification method). "Frequently Asked Questions" covers general hypospadias information, perioperative expectations and a review of postoperative care.

DISCUSSION

To our knowledge, this is the first DA prototype developed for a pediatric urology condition using a human-centered design approach to engage many key stakeholders in the development process. One limitation of this study is the small population sampled, which limits generalizability and means that our findings may not reflect the views of all parents or pediatric providers involved in hypospadias decision-making.

CONCLUSIONS

We created a parent-centered hypospadias DA prototype that provides decision support in an online, interactive format. Future directions include further testing with usability experts, providers and parents.

Development of a prediction model for postoperative complications after primary hypospadias correction

PURPOSE

To develop a prediction model for postoperative complications after primary one-stage hypospadias correction to improve preoperative parental counseling.

MATERIALS AND METHODS

In this retrospective cohort study, data were collected from 356 patients with anterior or middle hypospadias who had a one-stage hypospadias correction from 2003 onwards. Potential treatment- and patient-related factors were selected and used to develop a prediction model for postoperative complications within one year (wound-related complications, urinary tract infections, fistulas, stenosis, and prepuce-related complications). Multivariable logistic regression analysis with stepwise backward selection and a p-value of 0.20 was used to select the final model, which was internally validated using the bootstrap procedure.

RESULTS

Complications within one year postoperatively occurred in 66 patients (19%), of which 13% and 37% were seen in anterior and middle type of hypospadias, respectively. Hypospadias phenotype, surgical technique, chordectomy, and surgeon's experience were included in the final prediction model, whereas none of the patient-related factors were. The final model had a good discriminative ability (bias corrected C statistic 0.70) and calibration.

CONCLUSION

Using easily obtainable information, this model showed good accuracy in predicting complications within one year after hypospadias surgery. It is a first step towards individualized risk prediction of postoperative complications for anterior and middle hypospadias and can assist in preoperative parental counseling.

TYPE OF STUDY

Prognostic study.

LEVEL OF EVIDENCE

Level II.

A prospective study comparing modified foreskin reconstruction versus circumcision with tubularized incised plate urethroplasty for distal and mid penile hypospadias

BACKGROUND

In Asian countries and the Hispanic populations, parents of many hypospadias patient demands prepuce to be saved. Foreskin reconstruction is a technique for achieving the nearly natural appearance of hypospadias penis. In most distal and selected mid-penile hypospadias it may be performed. Numerous specialists, however, support circumcision for the concern that foreskin reconstruction may endanger the repair of urethroplasty leading to the risk of formation of fistulas.

AIM

To evaluate the surgical complications and outcome of modified foreskin reconstruction (MFR) versus circumcision with tubularized incised plate urethroplasty for distal and mid penile hypospadias.

METHODS

This prospective comparative study included 80 children with distal and mid penile hypospadias treated from 2017 to 2019 in tertiary referral hospital. Group 1, n = 40 underwent TIPU and MFR, and Group 2 included 40 patients for TIPU with circumcision.

RESULTS

In group 1, patients ranged from 2.2 to 6.5 years (mean 4.6 ± 1.52 years) and in group 2 ranged 2.6-7 years (mean 4.59 ± 1.43 years). Specific to group 1 preputial edema was seen in 29 patients at 2nd weeks, completely disappeared by 8^thweek. Retraction of prepuce was possible in 18 patients by 21 days and all but one by 6 months Foreskin wound gaping was seen in 1 at day 12 postoperatively and was repaired subsequently. Meatal stenosis was seen in one in both group, responded to urethral dilation by 6 weeks. Three patients from group 1 and 2 from group 2 developed urethral fistula which was subsequently closed. The complication rate was not statistically significant. Secondary phimosis was not seen in this study. A wide preputial opening was achieved during reconstruction in all patients in group 1.

DISCUSSION

One of the notable features, the absence of the prepuce, makes the patient conscious of the surgical procedure they had undergone. The specific complication of the preputial reconstruction is the presence of a non-retractile prepuce at the end of the surgery, secondary phimosis, preputial wound gaping, and dehiscence. In some patients, the distal portion of the prepuce becomes narrow, after vertical reconstruction. To prevent phimosis, the technique was improvised by taking transverse sutures in the distal part combined with midline approximation of the foreskin. This widens the preputial ring enabling smooth retraction of the reconstructed prepuce.

CONCLUSIONS

TIPU with MFR is an effective procedure for distal and selected mid penile hypospadias without increasing urethroplasty complications.

Study structure may compromise understanding of longitudinal decision regret stability: A systematic review

OBJECTIVES

To perform a systematic review of decision regret studies in cancer patients to determine if regret is longitudinally stable, and whether these study structures account for late-emerging treatment effects.

METHODS

Online databases including the George Mason Libraries, Global Health, Nursing and Allied Health, and PubMed were searched to identify decision regret studies with longitudinal components in patients with cancer.

RESULTS

A total of 845 unique citations were identified; 20 studies met inclusion criteria. Data was also collected on the time horizon for 90 studies; 47 % of studies evaluated regret at time points of one year or less, although this has increased significantly in prostate cancer citations since 2010. Regret was infrequent, affecting less than 20 % of patients, and often stable. Effect sizes in studies where decision regret changed over time were small to negligible.

CONCLUSION

Longitudinal effects can influence the expression of decision regret, yet many studies are not designed to collect long-term data; prostate cancer studies may be particularly disadvantaged. The degree of this influence in current studies is small, though this outcome must be interpreted with caution.

PRACTICE IMPLICATIONS

Providers should be aware of the risk of late-emerging regret and counsel patients appropriately.

Decision Regret among Informal Caregivers Making Housing Decisions for Older Adults with Cognitive Impairment: A Cross-sectional Analysis

Background. Informal caregivers are regularly faced with difficult housing decisions for older adults with cognitive impairment. They often regret the decision they made. We aimed to identify factors associated with decision regret among informal caregivers engaging in housing decisions for cognitively impaired older adults. Methods. We performed a secondary analysis of cross-sectional data collected from a cluster-randomized trial. Eligible participants were informal caregivers involved in making housing decisions for cognitively impaired older adults. Decision regret was assessed after caregivers' enrollment in the study using the Decision Regret Scale (DRS), scored from 0 to 100. We used a conceptual framework of potential predictors of regret to identify independent variables. We performed multilevel analyses using a mixed linear model by estimating fixed effects (β) and 95% confidence intervals (CIs). Results. The mean (SD) DRS score of 296 informal caregivers (mean [SD] age, 62 [12] years) was 12.4 (18.4). Factors associated with less decision regret were having a college degree compared to primary education (β [95% CI]: -11.14 [-18.36, -3.92]), being married compared to being single (-5.60 [-10.05, -1.15]), informal caregivers' perception that a joint process occurred (-0.14 [-0.25, -0.02]), and older adults' not having a specific housing preference compared to preferring to stay at home (-4.13 [-7.40, -0.86]). Factors associated with more decision regret were being retired compared to being a homemaker (7.74 [1.32, 14.16]), higher burden of care (0.14 [0.05, 0.22]), and higher decisional conflict (0.51 [0.34, 0.67]). Limitations. Our analysis may not illustrate all predictors of decision regret among informal caregivers. Conclusions. Our findings will allow risk-mitigation strategies for informal caregivers at risk of experiencing regret.

Provider perspectives on shared decision-making regarding hypospadias surgery

INTRODUCTION

Many parents experience decisional conflict and decisional regret around hypospadias surgery. The utilization of a shared decision-making (SDM) process may mitigate these issues, however addressing the principal components of the SDM process is a complex task that requires the investment of providers.

OBJECTIVE

The purpose of this study was to facilitate a discussion about SDM anchored on hypospadias with pediatric urology and general pediatric providers to explore perspectives, clinical applications and barriers to adopting SDM in clinical practice.

STUDY DESIGN

We conducted two focus groups in order to engage pediatric urology and general pediatric providers in guided discussions about SDM anchored on hypospadias. All activities were audio recorded and professionally transcribed. The transcripts were analyzed by three coders using directed qualitative content analysis techniques to identify themes and relationships between themes to inform the development of an affinity diagram (Extended Summary Figure).

RESULTS

Two focus groups were held; one with seven pediatric urology providers in November 2018 and one with ten general pediatric providers in January 2019 (median age 51 years, 88.2% Caucasian, 58.8% female, 70.6% physicians and 29.4% nurse practitioners). Both groups identified some of the key components of SDM including engaging families in decision-making, informing them about treatment options and clarifying values/preferences (Extended Summary Figure). They thought that SDM was useful for discussing preference-sensitive conditions (e.g. hypospadias) and addressing parental compliance. General pediatric providers also suggested that SDM helped them avoid unnecessary referrals to specialists. Both groups identified parental, provider and systemic barriers to the adoption of SDM: a) desire for paternalism, b) misperceptions about medical evidence, c) completion of parental decision-making prior to the clinical visit, d) provider bias/lack of interest and e) time constraints/productivity pressures.

DISCUSSION

Providers who care for hypospadias patients are knowledgeable about SDM and its potential clinical applications. They identified several potentially modifiable barriers to the adoption of a SDM process about hypospadias surgery in a pediatric clinical setting.

CONCLUSIONS

Based on feedback from providers, we plan to implement a hypospadias decision aid early in the parental decision-making process about hypospadias such as in the postpartum unit and at well-child visits in the newborn period and provide a provider training session about SDM to address the identified knowledge gaps.

Individualized care for patients with intersex (disorders/differences of sex development): part I

The care of individuals with disorders/differences of sex development aims to enable affected individuals and their families to have the best quality of life, particularly those born with severe genital ambiguity. Two of the biggest concerns for parents and health professionals are: (1) making a gender assignment and (2) the decisions of whether or not surgery is indicated, and if so, when is best for the patient and parents. These decisions, which can be overwhelming to families, are almost always made in the face of uncertainties. Such decisions must involve the parents, include multidisciplinary contributions, have an underlying principle of full disclosure, and respect familial, philosophical, and cultural values. Assignment as male or female is made with the realization that gender identity cannot be predicted with certainty. Because of the variability among those with the same diagnosis and complexity of phenotype-genotype correlation, the use of algorithms is inappropriate. The goal of this article is to emphasize the need for individualized care to make the best possible decisions for each patient's unique situation.

Knowledge gaps and information seeking by parents about hypospadias

INTRODUCTION

Parents making complex decisions about hypospadias surgery may experience anxiety and uncertainty related to multiple sources of information with questionable reliability and limited relevance to their concerns.

OBJECTIVE

The purpose of this study was to identify knowledge gaps, information-seeking behaviors, and informational needs of parents making decisions about hypospadias surgery as an initial step in the development of a hypospadias decision aid.

STUDY DESIGN

We conducted semi-structured interviews with English-speaking parents (≥18 years of age) of children with hypospadias, inquiring about gaps in their knowledge, information-seeking behaviors, and perceived informational needs (Extended Summary Table). We conducted interviews until no new themes were identified, analyzing them iteratively using open, axial, and selective coding. We used grounded theory methods to develop an explanation of the information-seeking process about hypospadias surgery.

RESULTS

Of the 43 eligible parents, 16 mothers and 1 father (39.5%) of 16 patients participated: 7 preoperative and 9 postoperative with distal (8) and proximal (8) meatal locations. Parents were aged 21-43: 15 Caucasians and 2 African-Americans. Educational backgrounds and marital status varied across subjects. We identified five categories of knowledge gaps relating to hypospadias surgery: 1) epidemiology, 2) timing/technique, 3) perioperative experience, 4) long-term cosmetic outcome, and 5) long-term risk of complications. Information-seeking behaviors included searching the internet, discussing hypospadias with the child's pediatrician and/or urologist, and obtaining information from their social network. Most parents sought information online prior to and/or after consultation with the urologist, from parent blogs/forums, medical school/hospital websites, journal articles, and medical databases. Perceived informational needs included clear and reliable information online, images of mild degrees of hypospadias, and images of repaired hypospadias cases. According to the parents, video testimonials from other parents would help them relate to others in their social network and build confidence about the surgical process.

DISCUSSION

The findings of this study contribute to our understanding of parental decision-making about hypospadias surgery by highlighting specific knowledge gaps and informational needs for inclusion in a decision aid. Study limitations include a small sample size that is typical and expected for qualitative research studies and the underrepresentation of fathers, minorities, and same-sex couples.

CONCLUSIONS

The Internet is the primary source of information most parents use to address knowledge gaps about hypospadias. Parents expressed concerns about the reliability and clarity of information and identified informational needs including parent testimonials and a wide variety of hypospadias images for inclusion in a decision aid.

Parental decisional satisfaction after hypospadias repair in the United Kingdom

BACKGROUND

In hypospadias, the aim of surgical treatment is to achieve both desirable functional and cosmetic outcomes; however, complications following surgery are common and 18% of boys require re-operation. In mild degrees of hypospadias, repair may be offered entirely to improve cosmesis, meaning parents should be fully informed of this and the potential for complications, during the consent process. Parents' decision-making may be aided by making them aware of how others in a similar position have felt about the decision that they made for their child. One method of measuring parental satisfaction is decisional regret (DR).

OBJECTIVES

To assess parental satisfaction following hypospadias surgery in the United Kingdom by assessing DR and to determine the feasibility of obtaining meaningful data via a mobile phone survey.

STUDY DESIGN

The National Outcomes Audit in Hypospadias database was commissioned by the British Association of Paediatric Surgeons to capture clinical information from hypospadias repairs. Following ethical approval (16/NW/0819), a text message was sent to mobile numbers in the database inviting participation in a questionnaire incorporating the validated DR scale (DRS). The primary outcome measure was mean DRS score, which was correlated with clinical information, a score of zero indicated no regret and 100 indicated maximum regret.

RESULTS

There were 340 (37%) responses. The median age at the primary procedure was 16 (interquartile range 13-20) months. No DR (score = 0) was detected in 186 (55% [95%CI 49-60]) respondents; however, moderate-to-severe DR (score = 26-100) was seen in 21 (6.2% [95%CI 3.6-8.7]) respondents. On multivariate analysis, a distal meatus, a small glans and developing complications requiring repeat surgery were all associated with increased levels of regret (Table). There was no association between DR and cases performed per surgeon.

DISCUSSION

Around half of respondents demonstrated no DR and postoperative complications requiring surgery were associated with the highest levels of DR, which is similar to a Canadian study. Lorenzo et al. however found that DR was associated with circumcision, which was undertaken in all boys; however, in this UK study, around a third of boys were circumcised and regret levels between those circumcised and those not circumcised were similar. The limitations of this work include the following: surgeons submitting their own data on complications and there is potential of selection bias between respondents and non-respondents as with any survey.

CONCLUSIONS

Data from this study can be used to improve pre-operative counselling during the consent process. Smart mobile phone technology can be used successfully to distribute and collect parent-reported outcomes.

Gender destinies: assigning gender in Disorders of Sex Development-Intersex clinics

Based on audio recordings of consultations in three U.S. paediatric multidisciplinary Disorders of Sex Development-Intersex clinics, we examine the process of gender assignment of children with "atypical" genitalia. Rather than fully determined by the presence of biological sex traits, the gender assignment discussion hinges on how clinician and parent collaboratively imagine different aspects of what constitutes being a gendered person. They orient towards the potential for sexual intimacy, fertility, gender dysphoria, stigma, and gonadal cancer risk. While these futures remain inherently uncertain, clinicians and parents plan to mobilise gender socialisation and medical interventions to render their choice of gender a self-fulfilling prophecy. Gender destinies capture that the child always had a specific, innate gender awaiting discovery, and presumes a project for medical and social monitoring, intervention, correction, and optimisation.

A shared decision-making tool for individuals living with complete androgen insensitivity syndrome

Reports exist regarding a gradual approach to the care of patients with differences of sexual development. Each patient and family have different values and styles of learning that have to be taken into account. The goals of care should include education about the condition, counseling of the patient and family, and a complete outlining of treatment options. Motivated by a call from the 2010 Health Reform Law for the use of shared decision-making tools and the emphasis placed on these issues by the DSD Consensus Statement, we sought to develop and implement such tools for the DSD population.^1-3 Thus, we developed an organized checklist for providers to share with a patients and families affected by CAIS, beginning with the initial visit. The development of the document enlisted input from physicians, clinical coordinator, advocacy groups and affected individuals. It allows providers to explain the process of care and develop a plan for delivery of that care over multiple visits spanning six months or more. The checklist is divided into five sections: 1) An overview addressing how much information is desired and in what manner the patient prefers to obtain information; 2) A preferred words list so that the patient can choose nomenclature that is most comfortable; 3) A list of topics to review over the course of multiple visits; 4) A list of questions to be answered by the providers or other resources over time, and; 5) A list of concerns to be addressed before surgical intervention is considered. An organized approach to long-term delivery of compassionate care and accurate information can be facilitated for patients with CAIS by the use of a shared decision-making checklist. Documentation of the care delivery process can stimulate referral to peer support and promote fully informed consent for treatment decisions. The use of the checklist should encourage trust in the provider, as well as aid in identifying and addressing stressors for the patient and family. The checklist will be updated and revised as new treatments and advanced technology emerges.

Parental perspectives on decision-making about hypospadias surgery

INTRODUCTION

Many parents who choose hypospadias repair for their son experience decisional conflict and regret. The utilization of a shared decision-making process may address the issue of decisional conflict and regret in hypospadias repair by engaging both parents and physicians in decision-making.

OBJECTIVE

The objective of this study was to develop a theoretical framework of the parental decision-making process about hypospadias surgery to inform the development of a decision aid.

STUDY DESIGN

We conducted semistructured interviews were conducted with parents of children with hypospadias to explore their role as proxy decision-makers, inquiring about their emotions/concerns, informational needs, and external/internal influences. Interviews were conducted until no new themes were identified, analyzing them iteratively using open, axial, and selective coding. The iterative approach entails a cyclical process of conducting interviews and analyzing transcripts while the data collection process is ongoing. This allows the researcher to make adjustments to the interview guide as necessary based on preliminary data analysis in order to explore themes that emerge from early interviews with parents. Grounded theory methods were used to develop an explanation of the surgical decision-making process.

RESULTS

Sixteen mothers and one father of seven preoperative and nine postoperative patients (n = 16) with distal (8) and proximal (8) meatal locations were interviewed. Four stages of the surgical decision-making process were identified: (1) processing the diagnosis, (2) synthesizing information, (3) processing emotions and concerns, and (4) finalizing the decision (Extended Summary Figure). Core concepts in each stage of the decision-making process were identified. Primary concerns included anxiety/fear about the child not waking up from anesthesia and their inability to be present in the operating room. Parents incorporated information from the Internet, medical providers, and their social network as they sought to relieve confusion and anxiety while building trust/confidence in their child's surgeon.

DISCUSSION

The findings of this study contribute to our understanding of decision-making about hypospadias surgery as a complex and multifaceted process. The overall small sample size is typical and expected for qualitative research studies. The primary limitation of the study, however, is the underrepresentation of fathers, minorities, and same-sex couples.

CONCLUSIONS

This study provides an initial framework of the parental decision-making process for hypospadias surgery that will inform the development of a decision aid. Future stages of decision aid development will focus on recruitment of fathers, minorities, and same-sex couples in order to enrich the perspectives of our work.

Level of agreement on postoperative complications after one-stage hypospadias correction comparing medical records and parent reports

PURPOSE

To analyze agreement on postoperative complications after hypospadias surgery according to medical records and parents' reports.

MATERIALS & METHODS

In this retrospective cohort study, data were collected from 409 children who received an initial one-stage hypospadias correction in the Radboudumc, The Netherlands. Postoperative complications according to medical records were compared with parent-reported complications in an online questionnaire. Main complications studied were wound-related complications, urinary tract infections, fistulas, stenosis, and prepuce-related complications. Agreement was determined by Cohen's kappa coefficient.

RESULTS

Slightly less complications were mentioned in medical records (37%) compared to parents' reports (42%). Overall agreement was moderate (κ = 0.50, 95% confidence interval (CI):0.41-0.59), but poor for some specific complications. Agreement was higher for complications that needed reoperation compared to when no reoperation was performed (κ = 0.53, 95% CI: 0.43-0.62 and κ = 0.18, 95% CI: 0.06-0.31) and for patients with recent surgery (<5 years before questionnaire completion) compared to less recent surgeries (κ = 0.69, 95% CI: 0.55-0.84 and κ = 0.43, 95% CI: 0.33-0.54).

CONCLUSIONS

Agreement on complications according to medical records and parents' reports was poor to moderate, but better after reoperation and more recent surgery. Some complications mentioned in medical records were missing from parents' reports and the other way around. Better agreement will give physicians and parents a more reliable view on postoperative outcome after hypospadias surgery.

TYPE OF STUDY

Diagnostic test.

LEVEL OF EVIDENCE

Level III.

Satisfaction, disappointment and regret surrounding fertility preservation decisions in the paediatric and adolescent cancer population

PURPOSE

With over 80% of paediatric and adolescent cancer patients surviving into adulthood, quality-of-life issues such as future fertility are increasingly important. However, little is known about regret around decisions to pursue or forgo fertility preservation (FP). We investigated the risk of decision regret in families involved in making a FP decision and explored contributive factors.

METHODS

Parents and patients ≥ 15 years were invited to participate. Participants completed a 10-item survey, including a validated Decision Regret Scale. Scores ≥ 30 indicated high regret. Free-text response items allowed participants to provide reasons for satisfaction or regret.

RESULTS

A total of 108 parents and 30 patients participated. Most (81.4%) reported low regret (mean score 13.7). On multivariate analysis, predictors of low regret included having a FP procedure and a fertility discussion pre-treatment. Most participants believed that FP offers hope for future fertility. Some reported dissatisfaction with the process of decision-making.

CONCLUSION

Overall levels of regret in the study population were low, with factors associated with quality, timely discussion and belief in the success of FP technology being predictors of low regret. However, dissatisfaction with the decision-making process itself revealed that refinements to the programme are required to meet families' needs.