The 'learning curve' in hypospadias surgery

Can paediatric surgical registrars safely perform supervised hypospadias surgery?

INTRODUCTION

Hypospadias repair is regarded as a technically demanding, complex procedure, with variable outcomes. Therefore, it tends to be performed by consultants, with limited trainee involvement. We aimed to study the clinical outcomes of supervised registrars performing proximal and distal hypospadias repairs, compared to their consultant mentors.

METHODS

We undertook a retrospective review of all primary hypospadias repairs performed between April 2013-April 2022 at our tertiary paediatric urology centre. Redo repairs and patients lost to follow-up were excluded. Pre-operative anatomy, theatre time, grade of primary surgeon (registrar (trainees and non-training middle grades) or consultant), operative technique, follow-up duration, complications, and reoperation rates were recorded. The procedures were assessed in two groups according to the primary operator: registrar or consultant. The Zwisch scale is used to describe level of consultant support. Registrars as primary operators received "passive help" or "supervision" (Zwisch levels 3/4). Consultants as primary operators provided registrars with "show-and-tell" or "active help" (Zwisch levels 1/2).

RESULTS

270 procedures performed on 228 patients met the inclusion criteria. 109 were performed by registrars and 161 by consultants. In both groups, median age was two years (p = 0.23). Median theatre time was similar (registrars 2.8 h vs. consultants 2.7 h, p = 0.88), as was median follow-up (registrars 25months, vs. consultants 21months, p = 0.99). Operations performed by registrars were 76% distal and 24% proximal; and by consultants were 62% distal and 38% proximal. The overall urethroplasty complication rate was similar, at 24% for registrars and 23% for consultants (p = 0.89). The summary table shows the distribution of different complications. Re-operation rate was 16% in both groups (p = 0.99). Complications were further assessed according to operation type (TIP vs. two-stage repair).

DISCUSSION

Contrary to popular belief amongst hypospadiologists, we found complication rates were similar for registrar and consultant surgeons. We question that involvement of registrars increases complications. The literature demonstrates safety of trainee performance of limited steps of the procedure. However our institution permits registrars to perform up to the whole hypospadias repair under direct supervision, with no predefined limit to their involvement.

CONCLUSION

Paediatric surgical registrars can be safely supervised to have substantial involvement in proximal and distal hypospadias repair, without compromising the duration or outcomes of surgery. We hope that allowing more registrar involvement can lead to faster acquisition of surgical skills, whilst remaining under the safety of senior supervision. Increasing opportunities for those with an aptitude for hypospadias repair can equip them with skills and confidence for entering fellowship training.

Teaching hypospadias repair by utilising a novel 3D-printed silicon model: An initial assessment using structured trainee and trainer feedback

INTRODUCTION

Simulated paediatric surgical training is inherently advantageous and flourishing. Moreover, several working conditions resulted in reduced training hours, index and subspecialty cases encountered, and the COVID-19 pandemic affected elective surgery backlogs, hence training opportunities. Hypospadias repair is technically-demanding and requires a spectrum of dissective and reconstructive skills. We therefore aimed to test a 3D-printed silicon model for hypospadias repair, in the context of hands-on surgical training.

MATERIAL AND METHODS

Twenty-Seven trainees, under the supervision of 15 instructors, completed the activity. They were given a seminar to show the relevant anatomy, and 8 key steps of the exercise: (1)-degloving; (2)-urethral plate marking; (3)-incision; (4)-tubularisation; (5)-glansplasty/glanuloplasty; (6)-dartos layer preparation; (7)-preputioplasty and (8)-skin closure. Each trainee completed a structured feedback assessment. An on-site trainer supervised and evaluated each exercise. Trainees and trainers rated the model through the above steps from unsatisfactory-(1/5) to excellent-(5/5), presented herein via cross-sectional analysis.

RESULTS

Eleven-(40.7 %) trainees were in years:1-3 of specialist training, 10-(37 %) were in years:4-6, and 6-(22.2 %) were beyond year-6. Two-(7.4 %) trainees had nil-hypospadias experience, 16-(59.2 %) previously assisted in procedures or performed steps, 5-(18.5 %) performed whole procedures supervised and 4-(14.8 %) independently. Twenty-(74 %) trainees and 15-(100 %) instructors judged the model to resemble the anomaly. Seventeen-(63 %) trainees and 13-(86.6 %) instructors rated the material needle-penetrability ≥3/5, compared to human tissue. Sixteen-(59 %) trainees and 13-(86.6 %) instructors rated the material suture holding ≥3/5. Eleven-(73.3 %) trainees and 13-(86.6 %) instructors rated sutures' evenness and edge coaptability ≥3/5.

DISCUSSION

Hypospadias is an index operation, which requires precision skills. Simulated training in Paediatric Surgery and Urology is gaining importance. 3D-printed models are gaining a key role in simulated training. The study presents a novel 3D-printed high-fidelity silicon-based hypospadias model designed for hands-on training. A structured pathway to divide a standard hypospadias repair into key steps is displayed to ensure skill acquisition and stabilisation.

CONCLUSION

This 3D-printed silicon-based hypospadias model is proven useful for hands-on training. The fidelity can still improve, especially regarding suture holding of the material.

LEVEL OF EVIDENCE

LEVEL III.

Unaided Visual Inspection for Assessment of Penile Curvature in the Clinical Setting of Hypospadias Surgery: Survey of Members of Society of Pediatric Urology (India)

Purpose

To compare the accuracy of unaided visual inspection (UVI) to Software App measurement (SAM) of penile curvature (PC) during hypospadias surgery.

Methods

Seven clinical pictures of PC (15°-60°) taken during hypospadias repair were shared with 300 members of the Society of Pediatric Urology (India). The respondents were asked to assess the angles by UVI and indicate their preferred correction method of that PC. For each picture, the angles of curvature estimated by UVI were compared with the objective angle measured using an app (SAM), which was considered an accurate estimation. Statistical analysis was done using software; P<0.05 was considered as statistically significant.

Results

Ninety-one of 101 (90%) respondents preferred UVI to measure PC during hypospadias surgery. For 6/7 pictures, <40% of participants estimated the angle correctly by UVI (P < 0.001), with the difference in estimation being 3.6°-14.9°. For pictures with PC >30°, the error in UVI estimation was >10°, with no correlation between the accuracy of UVI estimate and surgeon experience. A significant proportion of surgeons chose the incorrect option for PC correction, which was the lowest (69%) for PC 35.8°.

Conclusions

Most surgeons preferred UVI to assess PC; UVI is an erroneous technique to measure PC angle, especially in the PC range 30°-60°, where the error was >10°. Most errors were an underestimation of the PC, irrespective of surgeon experience. There was a significant error in the choice of technique for PC correction for a PC of 35°. These results strongly support the objective assessment of PC using SAM during hypospadias repair.

Cumulative sum learning curve analysis of tubularized incised plate repair for hypospadias: a study of a single surgeon with a single surgical procedure

Purpose

To ascertain the quantity of instances by which a single surgeon achieves competency and proficiency in using tubularized incised plate (TIP) technique for the repair of distal and mid-shaft hypospadias using the cumulative sum (CUSUM) analysis.

Methods

We retrospectively evaluated patients with distal and mid-shaft hypospadias who were treated by a single surgeon between 2015 and 2021, using a single primary TIP technique with a de-epithelialized Byars flap. Data including type of hypospadias, age at surgery, curvature, operation time (OT), length of the reconstructed urethra, and postoperative outcomes were collected and assessed. CUSUM was used to assess the trends in OT and complication rate (CR) in order to generate the learning curve. The evolution of OT and CR can be divided into three phases: learning, competence, and proficiency.

Results

CUSUM identified three phases in the learning curves of all TIP repairs. The median OT decreased from 135 min [interquartile range (IQR) = 125-155] to 92 min (IQR = 80-100) (P < 0.001), CR decreased from 28 (28%) to 8 (5.3%) (P < 0.001), and reoperations decreased from 15 (15.2%) to 4 (2.6%) (P < 0.001). According to the CUSUM learning curve, technical competency plateaued after the 99th case, and both OT and CR entered a significantly declining proficiency phase after the 231st case. Further, when the neourethral length exceeded the total average, total complications, urethrocutaneous fistula, and reoperations increased (P = 0.013, P = 0.006, and P = 0.028, respectively).

Conclusions

Our study suggests that surgeons performing TIP repair may reach technical competency and achieve proficiency after operating on 99,231 cases, respectively. Moreover, the longer the neourethral length, the higher is the CR.

A Comparative Study on the Outcomes of Hypospadias Surgery Following Early Versus Late Bladder Catheter Removal

Background

Hypospadias is the most common penile malformation affecting up to one in 300 live male births. In general, a urinary diversion (urethral stent or bladder catheter) is maintained in situ for two to seven days or more after hypospadias repair. Because of the low level of evidence, the latest guidelines of the European Association of Urology and the European Society of Paediatric Urology provide no recommendations concerning the timing of catheter removal after hypospadias surgery. In this study, we aimed to compare the outcomes of hypospadias surgery (tubularized incised plate urethroplasty, TIPU) following early versus late bladder catheter removal.

Methodology

In total, 62 patients were included in this study. All patients underwent TIPU by the same team of surgeons. All patients were divided into the following two groups: group A (32 patients) had their catheter removed on or before the fifth postoperative day, and group B (30 patients) had their catheter removed after the fifth postoperative day. All patients were scheduled for an outpatient assessment after two weeks, at one month, after three months, and at six months if necessary.

Results

The mean age of patients in group A was five years (three to seven years) and in group B was five years (four to 7.25 years) with a p-value of 0.378. Among the early complications of the surgery, the occurrence of wound infections, urinary tract infections, and urinary retention was comparable among the two groups. The rate of bladder spasms (0% versus 13.3%, p = 0.033) was significantly higher in group B than in group A. The rate of urinary retention (12.5% versus 0%, p = 0.045) was significantly higher in group A than in group B. Superficial wound infection occurred in two out of 32 patients in group A (6.3%) and two out of 30 patients in group B (6.7%) (p = 0.94). Both groups had similar incidences of wound complications. Urinary tract infections also had a similar incidence in both early and late catheter removal groups, i.e., one out of 32 patients in group A (3.1%) and three out of 30 patients (10%) in group B (p = 0.271). Urinary extravasation following hypospadias repair occurred in two out of 32 patients (6.3%). No extravasation was noted in the late catheter removal group. However, the difference was not clinically significant (p = 0.164). Two patients in both groups developed urethrocutaneous fistula (6.3% in group A versus 6.7% in group B). However, the difference was not clinically significant. Meatal stenosis developed in three out of 32 patients in group A and two out of 30 patients in group B (9.4% versus 6.7%; p = 0.696). One patient in the early catheter removal group developed urethral stricture as a late complication. None of the patients in the late catheter removal group developed this complication.

Conclusions

The occurrence of long-term complications of TIP hypospadias repair was not affected by the early removal of the bladder catheter. The shortcomings of our study were its descriptive nature and the small sample size. Further prospective randomized controlled trials are needed to ascertain the safety of early catheter removal and improvement in quality of life in the immediate postoperative period.

Outcome of stented versus unstented mid-shaft to distal hypospadias repair

Aims

We compared the outcomes of unstented repair (UR) versus stented repair (SR) in patients with mid-shaft to coronal hypospadias (HS) to elucidate if SR has any advantage over the UR.

Materials and Methods:

We retrospectively studied our mid-shaft to coronal HS repair patients between January 2013 and January 2018. We recorded variables such as degree of HS, age at repair, surgeon, type of repair, suture used, stent usage, and standard early and late complications. Relative risk (RR) was calculated and P < 0.05 was considered significant.

Results:

We included 120 patients (63 UR, 57 SR). There was no statistically significant difference in any parameters in both the groups. All had either tubularized incised plate or Thiersch–Duplay procedure. Urethroplasty was done with PDS 6/0 in all cases. Trainees performed two-third of the repairs under variable supervision. Early complications included one UR patient having urinary retention needing insertion of urethral catheter, five SR patients having bleeding/swelling, and three UR having dysuria. All were managed conservatively. For late complications, 98 patients were available (UR: 51, SR: 47) with fistula in 17 (17.3%), UR 8 (15.6%) versus SR 9 (19.1%) (P = 0.5, RR = 1.2) meatal stenosis in 3, UR 3 versus SR 0 (P = 0.06, RR = 6.4) and glanular dehiscence 6, UR 4 versus SR 2 (P = 0.25, RR = 1.8).

Conclusion:

There were no statistically significant differences in the short-term complications between UR and SR for HS. In the long term, RR for meatal stenosis is higher in UR.

[Health care reality of selected pediatric urologic surgeries in Germany from 2006 to 2019]

BACKGROUND

The conservative and surgical treatment of children is a fundamental pillar of the urological specialist training program and represents one of the core competencies within urological healthcare. The loss of this expertise has been a reoccurring topic within urologic occupational policy. The aim of this study is to analyse actual case numbers and to compare the distribution and dynamics of pediatric urologic surgeries between the specialist departments of urology and pediatric surgery in Germany.

MATERIALS AND METHODS

We defined the surgical treatments of maldecensus testis, hypospadias, and vesicoureteral reflux (VUR) as index interventions. Using the tool reimbursement.INFO (RI Innovation GmbH, Hürth, Germany) we analysed publicly available quality report data of German hospitals between 2006 and 2019.

RESULTS

While orchidopexy was more commonly performed in the field of urology, the correction of hypospadias and the surgical treatment of VUR showed higher case numbers in the field of pediatric surgery. Proportionally, there was no relevant shift between urologic and pediatric surgical clinics for orchidopexy and surgical VUR therapy during the study period. For hypospadias corrections, the proportion of surgeries performed in pediatric surgical units is increasing (p < 0.0001). In pediatric surgery 84-93% of the analyzed procedures are performed in high-volume units, while this proportion is 56-73% in urology. In particular, a high proportion of VUR therapy in urology is performed as an occasional procedure (30% very low volume).

CONCLUSIONS

The quality report data enable the compilation of case numbers and the analysis of the distribution between urology and pediatric surgery in Germany. Merely the correction of hypospadias has shown a relevant shift towards pediatric surgery. The causes and possible consequences for professional policy of this preliminary investigation are complex and require further analysis.

Meta-analysis comparing the outcomes of single stage (foreskin pedicled tube) versus two stage (foreskin free graft & foreskin pedicled flap) repair for proximal hypospadias in the last decade

BACKGROUND

Despite many technical advances the debate continues on single versus staged procedures for proximal hypospadias. In this systematic review and meta-analysis we have compared the contemporary outcomes of proximal hypospadias repair: single stage foreskin pedicle tube (FPT) versus two stage foreskin free graft (FFG) and two-stage foreskin pedicled flap (FPF) over the last decade.

METHODS

A systematic literature review of publications in English of the following electronic databases was conducted: Cochrane Database, PUBMED, MEDLINE and EMBASE. The following keywords were used: (proximal) AND (hypospadias) AND (repair OR urethroplasty) AND (outcomes OR complications). The publication date range for studies was from January 2010 to December 2020. Outcomes analyzed were complications like urethro-cutaneous fistula (UCF), glans dehiscence (GD), meatal stenosis (MS), urethral stricture (US), urethral diverticulum (UD), recurrent curvature or residual chordee (RC), buried penis (BP) and poor cosmesis (PC) as per objective assessment scores, or poor graft uptake (PGF) during first stage. We also divided the papers based on case load into two groups: < 5 cases or >5 cases operated per year and compared the post-operative outcomes.

RESULTS

The I 2 statistics for prevalence of total complications showed high heterogeneity with I 2 of 88% for one stage repair and 92% & 98% for two stage repairs. The pooled data from 26 articles covered a total of 2664 patients; mean follow-up of 4.5 years (1.8-14 years). One stage repair (FPT) was used in 680 (25%) patients while two stage repair was used in 1984 (75%) patients. Complications were encountered in 285/680 (42%) of those who underwent single stage repair (FPT) and this was significantly higher (Fishers; p = 0.001) than 414/1984 (21%) complication rate seen in two stage repair. Among the two different techniques of two stage operations over-all complication rate was not significantly different (Fisher's; p = 0.1) between FFG (155/674; 23%) and FPF (259/1310; 20%). FFG was superior to FPF in terms of individual complications UCF, MS, GD and UD. For two-stage FPT and FPF repairs the complication rate significantly reduced (p = 0.01) with increasing case load. For single stage repairs the complication rate remained high despite the increasing case load.

CONCLUSIONS

Two-stage repair of proximal hypospadias had significantly less complications compared to single stage repair. Among two-stage repairs specific complications were significantly less for FFG, although total complications were not significantly different from that seen with FPF. The results of two-stage repairs improved with higher case load supporting the concept of dedicated hypospadias centres.

The learning curve in proximal hypospadias repair

INTRODUCTION

Although the learning curve in various surgical procedures is increasingly discussed, there have been only a few reports about the learning curve especially in proximal hypospadias repair.

OBJECTIVES

To evaluate the learning curve in one-stage hypospadias repair for proximal hypospadias.

MATERIALS AND METHODS

We retrospectively reviewed 73 cases of primary hypospadias repair by a single pediatric urologist using one-stage urethroplasty with a preputial skin graft between 2007 and 2018. The overall complication rate included fistula, glans dehiscence, and meatal stenosis. To analyze the impact of the surgeon's experience on the complication rate, we compared the complication rates among different groups of 20 consecutive cases each. In addition, we graphed the actual data of the operative time and cumulative complication rate to evaluate the learning curve. The cumulative complication rate was defined as the surgeon's complication rate (the number of complications accumulated at a time/number of cases at that time).

RESULTS

The median age at surgery was 18 months (range: 7-87). The median follow-up was 40 months (range: 3-114). In total, 13 (18%) children had complications: 9 fistulae, 3 glans dehiscence, and 2 metal stenoses. The analysis of each 20 cases revealed that the complication rate declined over time as the surgeon became more experienced. It was mainly attributed to a decline of the fistula rate. The diagram of the operative time showed a reduction with the increasing surgical experience. Additionally, the diagram of the cumulative complication rate demonstrated a plateau after 50 cases.

CONCLUSION

Our study showed the positive impact of surgeon experience on the outcome of one-stage repair for proximal hypospadias. In addition, the learning curve in proximal hypospadias repair stabilized after about 50 cases although the supervision of experienced surgeons is required during the early phase of learning curve.

Preoperative Topical Estrogen Treatment vs Placebo in 244 Children With Midshaft and Posterior Hypospadias

PURPOSE

Urethral fistula and dehiscence are common after hypospadias surgery. Preoperative androgens have been considered to reduce these complications although this consideration is not evidence-based. Dermatologists have reported the benefits of topical estrogens on skin healing. We investigated whether the preoperative use of topical promestriene could reduce healing complications in hypospadias surgery. Our primary objective was to demonstrate a reduction of healing complications with promestriene vs placebo. Impact on reoperations and other complications, clinical tolerance, bone growth, and biological systemic effects of the treatment were also considered.

METHODS

We conducted a prospective, randomized, placebo-controlled, double-blind, parallel group trial between 2011 and 2015 in 4 French centers. One-stage transverse preputial island flap urethroplasty (onlay urethroplasty) was selected for severe hypospadias. Promestriene or placebo was applied on the penis for 2 months prior to surgery. The primary outcome was the presence of postoperative urethral fistula or dehiscence in the first year postsurgery. For safety reasons, hormonal and anatomical screenings were performed.

RESULTS

Out of 241 patients who received surgery, 122 patients were randomized to receive placebo, and 119 patients received promestriene. The primary outcome was unavailable for 11 patients. Healing complications were assessed at 16.4% (19/116) in the placebo vs 14.9% (17/114) in the promestriene arm, and the odds ratio adjusted on center was 0.93 (95% confidence interval 0.45-1.94), P = 0.86.

CONCLUSIONS AND RELEVANCE

Although we observed an overall lower risk of complications compared to previous publications, postsurgery complications were not different between promestriene and placebo, because of a lack of power of the study or the inefficacy of promestriene.

The effect of intraurethral dexpanthenol in hypospadias repair: experimental rabbit study

INTRODUCTION

In this study, the authors aimed to research the histopathologic effects of intraurethral use of dexpanthenol for hypospadias repair. Dexpanthenol is a derivative of pantothenic acid, a B complex vitamin. Pantothenic acid is a molecule contributing in the structure of coenzyme A. It decreases the release of myeloperoxidase from granulocytes and inhibits the formation of free oxygen radicals, and it exhibits an anti-inflammatory effect by increasing mitotic activity.

OBJECTIVE

The objective of this study is to evaluate the use of dexpanthenol after a tubularized incised plate urethroplasty (TIP) on wound healing, inflammation, and fibrosis.

STUDY DESIGN

In this study, 18 healthy male New Zealand white rabbits weighing 2500-3000 g were used. The 18 rabbits were randomly divided into 3 groups. For the hypospadias model, rabbits had a urethral catheter inserted in the urethra and a ventral midline incision was made from the glans tip to the central line of the penis. Afterward, the incision was closed with Vicryl (7/0) using the continuous suture technique, and urethroplasty was completed. For fourteen days, group I had 0.9% saline solution administered intraurethrally twice per day with a 22G catheter sleeve (control group), group II had one dose of 500 mg/kg dexpanthenol (Bepanthene®; Bayer Turk Chemical Industry Limited Company, Turkey) ampoule and one dose of saline solution administered in the same way, and group III had two doses of 500 mg/kg dexpanthenol ampoule administered. On the fifteenth day, the penis was degloved and rabbits had penectomy performed with samples sent to the pathology department for histopathological assessment.

RESULTS

The degree of fibrosis and inflammation in group I (control group) was more severe than groups II and III. The differences between groups I and II were statistically significantly different for both fibrosis and inflammation (P = 0.018 and P = 0.041, respectively). The differences between groups I and III were also statistically significantly different for both fibrosis and inflammation (P = 0.019 and P = 0.011, respectively). Groups II and III were not different significantly for fibrosis and inflammation (P > 0.05).

DISCUSSION

This study shows that intraurethral dexpanthenol application has positive effects on fibrosis and inflammation. The main limitations of the study are that the hypospadias model was created surgically and long-term follow-up for fistula formation was not assessed.

CONCLUSIONS

Administration of intraurethral dexpanthenol after hypospadias repair has positive effects on fibrosis and inflammation.

Hypospadias surgery on YouTube: is it valid?

BACKGROUND

This study aims to evaluate video clips of hypospadias surgery on YouTube and to assess their competence for basic steps of hypospadias surgery.

METHODS

The YouTube was screened for videos of hypospadias surgery between 1 December 2018 and 20 December 2018. Videos were divided into three groups based on the subjective utility checklist scores as follows: highly compatible (group 1; ≥7 points), moderately compatible (Group 2; 5-6 points), and less compatible (group 3; ≤4 points). Groups were compared statistically.

RESULTS

A total of 100 videos were included in this study. The mean total score was 4.48±1.97. There were 15 (15%) videos in group 1, 42 (42%) in group 2, and 43 (43%) in group 3. There was a statistically significant difference in the total score, duration of videos, and like/dislike ratios among the groups (P<0.001, for all). There was a strong and significant correlation between the total scores and the step of glanuloplasty and skin closure (r: 0.805, P<0.001 and r: 0.770, P<0.001, respectively).

CONCLUSIONS

Our study results suggest that the educational content of the videos of hypospadias surgery on YouTube is unsatisfactory. We believe that such videos must contain information regarding the surgical steps of glanuloplasty, skin closure, flap transposition, and urethroplasty and detailed information about the suture materials.

Improving surgical training by identifying the most common feedback trainees receive for index cases

BACKGROUND

To make surgical training more effective, a proven method is needed to provide feedback to residents on their surgeries. Residency programs may make up for limited training time in the operating room by improving feedback that trainees receive about cases.

OBJECTIVE

The goals of this study were (1) to determine if an online tool to communicate feedback for attendings and trainees shows face validity and (2) to use an online tool to identify the most common feedback trainees receive after performing orchiopexy and hypospadias repair by survey.

METHODS

In 2016, determining whether an online tool to provide pediatric urology trainees feedback after surgery shows face validity begun. The tool was launched at the authors' institutions. Then, attendings, fellows, and postgraduate year 4-5 trainees of 65 resident training programs were surveyed for their observations on preparing for and performing orchiopexy and hypospadias repair using the study tool to identify common feedback.

RESULTS

The results of using the tool to provide feedback shows face validity are as follows: feedback was exchanged between attendings and trainees on orchiopexy (n = 28) and hypospadias (n = 22). Anecdotally, the tool was easy to use. The results of using the tool to identify the most common feedback trainees receive by survey are as follows: from a pool of 65 institutions, 37 attendings and 28 trainees were enrolled who made 219 observations. Most trainees prepare using undocumented online resources (17/28, 67%) instead of speaking with their attendings or cotrainees (11/28, 33%). For orchiopexy, most respondents reported that trainees need to improve skills for hernia ligation (observations: attending = 28/45, 62%; and trainee = 17/26, 65%) and strategies for hernia exposure (observations: attending = 17/27, 62%; and trainee = 7/12, 58%). For hypospadias, most respondents reported that trainees need to improve skills for neourethroplasty (observations: attending = 31/53, 58%; and trainee = 10/16, 62%) and strategies for repair choice (observations: attending = 15/22, 68%; and trainee = 12/18, 67%) (chi-squared, all P = NS).

DISCUSSION

It was shown that both trainees and attendings agree on the areas of surgical strategy and execution which require improvement. With this study, it is also shown that the online feedback tool developed shows face validity in allowing attendings and trainees to communicate before and after surgery.

CONCLUSIONS

The most common feedback pediatric urology trainees receive for routine pediatric urology surgery is identified. Online tools that emphasize remediations to address a trainee's specific feedback needs are to be built, so that they will be able to improve their skills at their next case.

Advances in paediatric urology

Paediatric urological surgery is often required for managing congenital and acquired disorders of the genitourinary system. In this Series paper, we highlight advances in the surgical management of six paediatric urological disorders. The management of vesicoureteral reflux is evolving, with advocacy ranging from a less interventional assessment and antimicrobial prophylaxis to surgery including endoscopic injection of a bulking agent and minimally invasive ureteric reimplantation. Evidence supports early orchidopexy to improve fertility and reduce malignancy in boys with undescended testes. A variety of surgical techniques have been developed for hypospadias, with excellent outcomes for distal but not proximal hypospadias. Pelvi-ureteric junction obstruction is mostly detected prenatally; indications for surgery have been refined with evidence, and minimally invasive pyeloplasty is now standard. The outlook for patients with neurogenic bladder has been transformed by a combination of clean intermittent catheterisation, algorithms of diagnostic investigations, and innovative medical and surgical therapies. Posterior urethral valves are associated with considerable mortality; fetal diagnosis allows stratification of candidates for intervention, but ongoing bladder dysfunction in patients after valve ablation remains a cause of long-term morbidity.

Impact of changing trends in technique and learning curve on outcome of hypospadias repair: An experience from tertiary care center

Introduction:

Apart from numerous clinical factors, surgical experience and technique are important determinants of hypospadias repair outcome. This study was aimed to evaluate the learning curve of hypospadias repair and the impact of changing trends in surgical techniques on the success of primary hypospadias repair.

Materials and Methods:

We retrospectively analyzed of data of 324 patients who underwent primary repair of hypospadias between January 1997 and December 2013 at our center. During the initial 8 years, repairs were performed by multiple 5 different urologists. From 2005 onwards, all procedures were performed by a single urologist. The study cohorts was categorized into three groups; Group I, surgeries performed between 1997–2004 by multiple surgeons, Group II, between 2005–2006 during the initial learning curve of a single surgeon, and Group III, from 2007 onwards after completion of the learning curve of the single surgeon. The groups were compared in respect to surgical techniques, overall success and complications.

Results:

Overall 296 patients fulfilled the inclusion criterion, 93 (31.4%), 50 (16.9%), and 153 (51.7%) in Group I, II, and III, respectively. Overall success was achieved in 60 (64.5%), 32 (64%), and 128 (83.7%) patients among the three groups respectively (P < 0.01). Nineteen (20.4%), 20 (40%), and 96 (62.7%) patients underwent tubularized incised plate repair in Group I, II, and III, with successful outcome in 12 (63.2%), 15 (75%), and 91 (94.8%) patients, respectively (P < 0.01). The most common complication among all groups was urethrocutaneous fistula, 20 (21.5%) in Group I, 11 (22%) in Group II, and 17 (11.1%) in Group III.

Conclusion:

There is a learning curve for attaining surgical skills in hypospadias surgery. Surgeons dedicated for this surgery provide better results. Tubularized incised plate urethroplasty appear promising in both distal and proximal type hypospadias.

Results of distal hypospadias repair after pediatric urology fellowship training: A comparison of junior surgeons with their mentor

BACKGROUND

Teaching and learning hypospadias repair is a major component of pediatric urology fellowship training. Educators must transfer skills to fellows, without increasing patient complications. Nevertheless, few studies report results of surgeons during their first years of independent practice.

PURPOSE

To review outcomes of distal hypospadias repairs performed during the same 2-year period by consecutive, recently matriculated, surgeons in independent practice, and to compare them to results by their mentor (with >20 years of experience).

MATERIALS

Exposure to hypospadias surgery during fellowship was determined from case logs of five consecutive fellows completing training from 2007-2011. TIP was the only technique used to repair distal hypospadias. No fellow operated independently or performed complete repairs under supervision. Instead, the first 3 months were spent assisting their mentor, observing surgical methodology and decision-making. Then, each performed selected portions under direct supervision, including: degloving, penile straightening, developing glans wings, incising and tubularizing the urethral plate, creating a barrier layer, sewing the glansplasty, and skin closure. Overall fellow participation in each case was <50%. In 2011-2012, urethroplasty complications (fistula, glans dehiscence, meatal stenosis, urethral stricture, diverticulum) were recorded for consecutive patients undergoing primary distal repair by these recent graduates in their independent practices. The fellow graduating in 2011 provided 1 year of data. All patients undergoing repair during the study period were included in the analysis, except those lost to follow-up after catheter removal. Composite urethroplasty complications were compared between junior surgeons, and between junior surgeons and their mentor, with Fisher's exact contingency test.

RESULTS

Training logs indicated fellow participation ranged from 76-134 hypospadias repairs, including distal, proximal and reoperative surgeries. Post-graduation case volumes ranged from 25-68 by junior surgeons versus 136 by the mentor. With similar mean follow-up, urethroplasty complication rates were statistically the same between the former fellows, and between them versus the mentor, ranging from 5-13%. Nearly all were fistulas or glans dehiscence. Junior surgeons reported they performed TIP as learned during fellowship, with one exception who used 7-0 polydioxanone rather than polyglactin for urethroplasty.

DISCUSSION

This is the first study directly comparing hypospadias surgical outcomes by recently graduated fellows in independent practice with those of their mentor. We found junior surgeons achieved similar results for distal TIP hypospadias repair. Although their participation during training largely comprised observation and surgical assistance, with discrete performance of key steps, skills sufficient to duplicate the mentor's results were transferred. These data suggest there should be no learning curve for distal hypospadias after training. This report raises several considerations for surgical educators. First, mentors should review their own results, to be certain that they are correctly performing and teaching procedures. Second, programs need to determine key steps for procedures they teach, and then emphasize their optimal performance. Finally, mentors should expect former fellows to report back their initial results of hypospadias repair to be certain lessons taught were learned. Otherwise, preventable complications resulting from technical errors will be multiplied in the children operated by their trainees as they enter independent practice.

Management of adults with prior failed hypospadias surgery

Hypospadias is one of the most prevalent anomalies of the male genitalia. Contemporary hypospadias repair is very successful, but patients that have the surgery fail often require multiple surgeries throughout their life. Complications from failed hypospadias repairs have a significant impact on patients both psychologically and physically. Failed hypospadias repair encompasses a spectrum of problems that include hypospadias recurrence with an ectopic meatus, urethral fistula, urethral stricture, and ventral penile curvature. Repairs of hypospadias complications can be challenging due to the poor quality of surrounding tissue from disruption of normal vasculature in the re-operative field associated with the underlying disorder. One of the most challenging issues is dealing with urethral strictures. There have been multiple methods described at repairs of these in both a single stage and multiple staged procedures. Particular attention has been directed towards applications of grafts due to worse outcomes with flaps. Buccal mucosa has emerged as the leading graft material in staged repairs. When counseling patients with failed hypospadias it is important to discuss the expected outcome as repairs directed towards a terminally positioned meatus with a straight phallus may require multiple surgeries due to post-operative complications as well as the necessity of proceeding in a staged approach.

Inpatients hypospadias care: trends and outcomes from the American nationwide inpatient sample

PURPOSE

Hypospadias is the most common congenital penile anomaly. Information about current utilization patterns of inpatient hypospadias repair as well as complication rates remain poorly evaluated.

MATERIALS AND METHODS

The Nationwide Inpatient Sample was used to identify all patients undergoing inpatient hypospadias repair between 1998 and 2010. Patient and hospital characteristics were attained and outcomes of interest included intra- and immediate postoperative complications. Utilization was evaluated temporally and also according to patient and hospital characteristics. Predictors of complications and excess length of stay were evaluated by logistic regression models.

RESULTS

A weighted 10,201 patients underwent inpatient hypospadias repair between 1998 and 2010. Half were infants (52.2%), and were operated in urban and teaching hospitals. Trend analyses demonstrated a decline in incidence of inpatient hypospadias repair (estimated annual percentage change, -6.80%; range, -0.51% to -12.69%; p=0.037). Postoperative complication rate was 4.9% and most commonly wound-related. Hospital volume was inversely related to complication rates. Specifically, higher hospital volume (>31 cases annually) was the only variable associated with decreased postoperative complications.

CONCLUSIONS

Inpatient hypospadias repair have substantially decreased since the late 1990's. Older age groups and presumably more complex procedures constitute most of the inpatient procedures nowadays.

Byars two-stage procedure for hypospadias after urethral plate transection

OBJECTIVE

To report on the outcomes of primary hypospadias repaired with the Byars two-stage procedure.

MATERIALS AND METHODS

Primary hypospadias repairs with the Byars two-stage procedure, between 2009 and 2012, were retrospectively reviewed. Medical charts were reviewed and analyzed. Follow up was at two weeks, three months, six months and one year after surgery. Complications, which included fistula, glans dehiscence, meatal stenosis, urethral stricture, diverticulum, recurrent penile curvature and others, were documented and analyzed.

RESULTS

One hundred and twenty-eight cases were included in the present study. The median follow up was 30 months (range 13-44 months). All flaps took successfully after the first stage. Overall complication rates were 11.8%. Complications included: seven cases of fistula; five glans dehiscence; two urethral strictures, which developed after fistula repair; and one concealed penis. No recurrent penile curvature was recorded.

CONCLUSIONS

The Byars two-stage procedure is an option for primary hypospadias when the urethral plate is transected. It had an 11.8% complication rate in this present study.

Cumulative summation (CUSUM) charts in the monitoring of hypospadias outcomes: a tool for quality improvement initiative

OBJECTIVE

Cumulative summation (CUSUM) charting is a statistical tool that allows an individual surgeon or surgical department to monitor any binary outcome and rapidly detect when complications are outside the acceptable limits. We applied CUSUM statistical analysis to hypospadias repair to utilize the results in our own quality Improvement process.

MATERIALS AND METHODS

An institutional review board-approved retrospective review of all patients who underwent hypospadias repair by a single fellowship trained pediatric urologist at a single institution between September 2004 to July 2009 was performed. To graphically represent the complication rates and to assess for unacceptable rates, the use of CUSUM control charting was employed.

RESULTS

In our retrospective review, there were a total of 184 patients who underwent a total of 203 surgeries. Using CUSUM analysis, our incidence of major complications was within acceptable limits until approximately the first 150 operations had been performed, at which time the complication rate fell below the lower limit, indicating performance exceeded expectations.

CONCLUSION

CUSUM statistical charting was successfully applied to the retrospective monitoring of hypospadias outcomes at our institution. This is the first known publication in which CUSUM charts were used to evaluate complications of hypospadias repair.

Learning curve for TIP urethroplasty: A single-surgeon experience

INTRODUCTION

We evaluate the influence of surgeon experience and other clinical factors on the success of primary hypospadias repair, using the tubularized incised plate urethroplasty (TIPU) technique.

METHODS

We retrospectively reviewed pediatric cases of primary hypospadias repair performed by a single pediatric urologist (soon after his fellowship training) using TIPU between July 2002 and January 2011. The surgical techniques (including the fact that the procedure was an outpatient one) were the same for each patient. The overall complication rate (CR) was analyzed for the following factors: patient age, use of a stent, meatal position, and surgeon experience. All significant covariates on univariate analysis or with a clinical relevance were entered into a multivariable logistic regression model. A non-linear model was created to estimate the change in the CR over the years.

RESULTS

Pediatric patients (median age 1.4 years old) presenting with distal (n = 251), midshaft (n = 22) or proximal (n = 30) hypospadias and with a minimum 6-week follow-up (median 13 months) were included. Most patients (87%) had a urethral stent postoperatively (mean duration 9.8 days). In total, 96 patients had 133 complications: 27 meatal stenosis, 25 meatal coronal migrations, 22 urethrocutaneous fistulas and 59 other complications. Of these, 53 patients underwent a second operation. On multivariate analysis, the only factor increasing the CR was a non-distal meatus. The non-linear model demonstrated a significant learning curve with a decreasing CR over the years. The limitations of this study are its retrospective nature and lack of long-term follow-up.

CONCLUSIONS

When using TIPU, the CR significantly increases as the meatal position gets more proximal; the learning curve stabilizes after about 50 to 75 cases.

Hypospadias repair: a single centre experience

Objectives. To determine the demographics and analyze the management and factors influencing the postoperative complications of hypospadias repair. Settings. Hayatabad Medical Complex Peshawar, Pakistan, from January 2007 to December 2011. Material and Methods. All male patients presenting with hypospadias irrespective of their ages were included in the study. The data were acquired from the hospital's database and analyzed with Statistical Package for Social Sciences (SPSS). Results. A total of 428 patients with mean age of 8.12 ± 5.04 SD presented for hypospadias repair. Midpenile hypospadias were the most common. Chordee, meatal abnormalities, cryptorchidism, and inguinal hernias were observed in 74.3%, 9.6%, 2.8%, and 2.1% cases, respectively. Two-stage (Bracka) and TIP (tubularized incised urethral plate) repairs were performed in 76.2% and 20.8% of cases, respectively. The most common complications were edema and urethrocutaneous fistula (UCF). The complications were significantly lower in the hands of specialists than residents (P-value = 0.0086). The two-stage hypospadias repair resulted in higher complications frequency than single-stage repair (P value = 0.0001). Conclusion. Hypospadias surgery has a long learning curve because it requires a great deal of temperament, surgical skill and acquaintance with magnifications. Single-stage repair should be encouraged wherever applicable due to its lower postoperative complications.

Current practice in paediatric hypospadias surgery; a specialist survey

AIM

To undertake an online survey of current hypospadias surgery practice among those specialists attending the IVth World Congress of the International Society for Hypospadias and Disorders of Sex Development (ISHID), 2011.

MATERIALS AND METHODS

An online survey covering 22 separate questions relating to proximal and distal hypospadias surgery was set up, and all delegates registered for the conference were invited to complete this questionnaire anonymously. The data was analysed by three of the authors.

RESULTS

A total of 162 delegates registered for the conference of whom 74% were paediatric surgeons, paediatric urologists, plastic surgeons and adult/adolescent urologists. 93 delegates completed the online survey, and most of them (57%) were from Europe. The majority of surgeons see over 20 new patients/year (90%) and perform primary hypospadias surgery in over 20 patients/year (76%). The tubularized incised plate (TIP) repair is the most frequent technique used for the management of distal hypospadias (59%); other techniques used included Mathieu, onlay and TIP with graft. A variety of techniques are used for proximal hypospadias, but nearly half of the respondents (49%) preferred a staged approach. Self reported complication rates for distal hypospadias surgery are favourable (less than 10%) for 78% of the respondents. However, proximal hypospadias complication rates are higher.

CONCLUSIONS

With a majority of paediatric urologists and European delegates responding to our survey, the results suggest that there are differences in the management of proximal and distal hypospadias between surgeons, yet no differences were observed according to the region of their practice. Variations in long-term outcomes appear to be in keeping with the current literature.

Pediatric open partial nephrectomy: analysis of contemporary outcomes with a supracostal-12 approach

OBJECTIVE

Reports in the literature increasingly have demonstrated a shorter length of stay (LOS) with the laparoscopic approach to partial nephrectomy compared to historic open partial nephrectomy. We present data from the largest open series to date, to provide a more contemporary perspective.

METHODS

A retrospective review was performed on all pediatric patients who underwent upper pole partial nephrectomy from 1999 to 2011. Using univariate and multivariate linear regression, the associations between multiple explanatory covariates and outcomes such as pain and length of stay were analyzed.

RESULTS

Twenty-five surgeries were performed via a supracostal-12 approach. The mean incision length and operative time was 3.7 cm and 137 min, respectively. The average pain score was 1.7/10 and 72% of patients did not require morphine. The mean LOS was 36 h and all patients with postoperative imaging had normal blood flow. Multivariate analysis demonstrated that a later date of surgery was the only covariate significantly associated with decreased operative time and LOS.

CONCLUSION

Open partial nephrectomy can be performed in a minimally invasive manner via a small supracostal-12 incision with minimal pain and LOS. Surgeon experience is associated with decreased operative time and LOS. These contemporary open results should be considered when comparisons are made with laparoscopic surgery.

Different outcomes of hypospadias surgery between north america, europe and china: is patient age a factor?

Background and Objects

The patient’s age at the first hypospadias repair may be an important factor for determining postoperative outcomes. Age at the first procedure differs between Western countries and medical centers in China. This review examines the differences between the incidence of surgical complications and surgical age in boys receiving hypospadias repairs in North America, Europe and China.

Materials and Methods

Literature reports were reviewed in PubMed and WanFang databases using the key terms and phrases; ‘hypospadias outcomes’, ‘complications of hypospadias repair’ and ‘timing of hypospadias repair’. All peer-reviewed articles published over the past decade (2001-2011) were considered if; a full text was available, the article included age at the first hypospadias procedure and surgical complications.

Results

In total, 16 131 patients were reported in 113 papers from North America, Europe and China according to our inclusion criteria. There was a significant difference in age at the first hypospadias surgery (P < 0.0005) and in the incidence of complications (P <0.001) between the different global regions investigated, with the earliest surgeries occurring in North American patients. Urethral fistulas were the most common complication reported in all of the regions included in this study.

Conclusions

Fellowship training in pediatric urology could improve surgical outcomes, particularly in young children. Younger children experience fewer complications following hypospadias surgeries, independent of training and access to resources.

Tubularized incised plate repair for penoscrotal hypospadias: role of surgeon's experience

OBJECTIVE

To give a retrospective analysis of factors affecting outcome of tubularized incised plate (TIP) repair for penoscrotal hypospadias.

METHODS

Data of all patients who underwent TIP repair for penoscrotal hypospadias by a single surgeon were retrieved. Follow-up was carried out every 3 months within the first year and annually thereafter. Repairs were divided into 2 groups: Group 1 included surgeries performed in the first 2 years after fellowship training, and group 2 included repairs performed afterward. Chi-square test was used for statistical analysis. Statistical significance was defined as P<.05.

RESULTS

Data for 90 patients were retrieved for july 2001 through march 2009: Group 1 included 20 patients and group 2 included 70. The neourethra was covered with spongioplasty in 25 and dartos flap in 65. The overall success rate was 86%. Group 2 patients showed a statistically significant higher success rate of 91% compared with only 65% for group 1. Use of dartos flap was associated with statistically significant higher success (92%) compared with coverage of the neourethra with spongioplasty (68%). In group 1, use of dartos flap was associated with statistically significant better success (82% vs 33%). In group 2 patients, use of dartos flap showed no statistically better success (94% vs 81%).

CONCLUSIONS

TIP is a valid procedure for repair of penoscrotal hypospadias with chordee<30 degrees. The overall success (86%) is satisfactory. Surgeon's experience is the pillar for better success.

A model of delivering multi-disciplinary care to people with 46 XY DSD

In 2006, a consensus statement was jointly produced by the Lawson Wilkins Pediatric Endocrine Society (LWPES) and the European Society of Paediatric Endocrinology (ESPE) concerning the management of disorders of sex development (DSD) [1]. A recommendation provided by this consensus was that evaluation and long-term care for people affected by DSD should be performed at medical centers with multi-disciplinary teams experienced in such conditions. Here we provide our team's interpretation of the 2006 consensus statement recommendations and its translation into a clinical protocol for individuals affected by 46 XY DSD with either female, or ambiguous, genitalia at birth. Options for medical and surgical management, transitioning of care, and the use of mental health services and peer support groups are discussed. Finally, we provide preliminary data to support the application of our model for delivering multi-disciplinary care and support to patients and their families.

Functional, cosmetic and psychosexual results in adult men who underwent hypospadias correction in childhood

OBJECTIVE

Long-term results of hypospadias repair are scarce. Previous reviews mostly described mid-term results making extrapolation to long-term results difficult. This systematic review on long-term results in postpubertal men after hypospadias repair in childhood, aims to inform urologists and parents of a newborn boy with hypospadias about future expectations.

METHODS AND MATERIALS

The Pubmed/Medline and Embase databases were searched until February 2010. Inclusion criteria stated that patients with hypospadias were operated before the age of 6 years and were older than 14 years at follow up. Results were pooled and analyzed using SPSS 16.0. Data on proximal hypospadias patients and controls are described separately.

RESULTS

Twenty eligible studies investigating micturition, cosmesis and psychosexual functioning were found. Hypospadias patients report more urinary symptoms and have a lower Qmax than controls. Patients are less satisfied with penile appearance compared to controls. Objectively assessed cosmetic results are good. Sexually, patients are as active as controls, but are less satisfied. Patients less often have an intimate relationships compared to controls.

CONCLUSION

Study outcomes were heterogeneous due to operation techniques and a lack of validated questionnaires and control groups. Long-term results of hypospadias patients should be measured in a prospective design using validated measurement tools.

Outcome analysis of tubularized incised urethral plate using dorsal dartos flap for proximal penile hypospadias repair

PURPOSE

To assess the outcome of tubularized incised plate (TIP) urethroplasty in conjunction with a dorsal dartos flap for primary proximal penile hypospadias.

MATERIALS AND METHODS

Forty-nine patients with proximal penile hypospadias underwent a one-stage TIP urethroplasty with single-layer closure using polyglactin suture. A dorsal dartos (subcutaneous) flap, harvested from the dorsal penile shaft was used to cover the neourethra ventrally. Glanuloplasty was also performed in all cases. All patients had a well preserved urethral plate after straightening of the penis. Complications and cosmetic appearance were documented during follow-up.

RESULTS

Mean patient age at surgery was 23 months (16-72 months). Mean operative time was 180 min (154-240 min). At the mean follow-up of 36 months, the overall complication rate was 12% (4 fistulae, 1 meatal stenosis). Glandular dehiscence occurred in one patient, and 38 patients (78%) required dorsal Nesbit plication. No patient had residual chordee, neourethral stricture or a urethral diverticulum, and the neomeatus with a slit-like appearance was positioned at the glans tip.

CONCLUSIONS

TIP urethroplasty with dorsal dartos layer covering the neourethra is an effective treatment for primary proximal penile hypospadias with a preserved urethral plate and without severe curvature. There is a good cosmetic outcome with low risk of complications.

Urinary function after Snodgrass repair of distal hypospadias: comparison with the Mathieu repair

PURPOSE

To evaluate urinary function in patients with distal hypospadias undergoing repair by the tubularized incised-plate urethroplasty (TIP or Snodgrass), compare the results with those in patients treated by the Mathieu technique, and show the potential issues inherent to the evaluation of such results.

PATIENTS AND METHODS

A cross-sectional assessment was performed of uncomplicated distal hypospadias operated on during a 3-year period, already toilet trained, and able to void volitionally. Evaluation included clinical assessment urinary symptoms and urinary stream, and uroflowmetry.

RESULTS

Out of 83 patients operated on during the study period, 10 (12%) developed complication and 32 were not toilet trained or refused to participate in the study. Median follow-up in the remaining 41 patients included in the study was 20 (3-36) months. None of these patients presented voiding symptoms or urinary stream abnormalities. Uroflowmetry was normal in 30 cases and obstructive in 11 (27%). An obstructive flow pattern was more common in patients undergoing TIP versus Mathieu repair, 8 of 19 (42%) versus 3 of 22 (14%), respectively (P = 0.07). Four TIP cases with an obstructive uroflow pattern were managed conservatively.

CONCLUSIONS

Although both the TIP and the Mathieu repair allow good results in terms of urinary function after distal hypospadias repairs, the TIP technique seems more likely to be associated with urine flow pattern abnormalities. The actual clinical relevance of this finding remains ill defined.

Hypospadias outcome in the first 3 years after completing a pediatric urology fellowship

INTRODUCTION

The requirements of hypospadias surgery today not only include the creation of a straight phallus with optimal meatal placement but also call for excellent cosmetic outcomes with minimal complications. Specialty fellowship training as well as advanced surgical materials and techniques allow for consistent, successful results. We report the outcomes of hypospadias surgeries performed by two academic Pediatric Urologists in the first 3 years of practice after completing a 2-year fellowship.

PATIENTS AND METHODS

A retrospective chart review of all patients with hypospadias treated by two surgeons (DF and JC) between July 2004 and August 2007 was performed. The two surgeons had completed a 2-year Pediatric Urology fellowship at two different institutions (Johns Hopkins and Texas Children's Hospital). Level of hypospadias, patient age, type of repair and follow up as well as complications were recorded. Midshaft and distal hypospadias were classified as distal.

RESULTS

In all, 187 patients were operated on. No significant difference in numbers and complications occurred between the two surgeons. Distal hypospadias was found in 149, proximal in 29, and penoscrotal or perineal was found requiring a two-stage repair in nine patients. Distal hypospadias was repaired using either dorsal plate incision with tubularization (TIP) (n=112) or meatal advancement and glanuloplasty (MAGPI) (n=37). All proximal lesions were repaired using TIP. All patients were seen after 1-2 weeks, and 6 and 12 months postoperatively. Fistulae occurred in 10 patients (three in distal, four in proximal, and three in two-stage repairs) for an overall fistula rate of 5.3%. Meatal obstruction occurred in three distal repairs and one two-stage repair, diverticulum in one proximal. No complications occurred with MAGPI repairs. All complications, except for one, were successfully repaired in a single operation.

CONCLUSION

Modern hypospadias surgical techniques pioneered through decades of surgical innovation can now be successfully transferred to the new generation of specialty-trained Pediatric Urologists. Modern pediatric fellowship training allows performing distal hypospadias repair with a minimal fistula rate of 2.8%. Proximal hypospadias remain more challenging with complication rates of 13.8% for one-stage and 33.3% for two-stage repairs.

Training residents in hypospadias repair: variations of involvement

PURPOSE

Hypospadias repair is a complex and seminal procedure that has defined the subspecialty of pediatric urology. We sought to determine the degree of training and opinions regarding the need for fellowship training to achieve necessary competence in hypospadias repair.

MATERIALS AND METHODS

An electronic survey was sent to 518 urology residents and recent graduates, and to 168 practicing pediatric urologists. Nonresponders were resent the survey 2 additional times. The survey consisted of basic questions on level of training or years in practice. Residents and practicing pediatric urologists were asked about the level of resident participation for each step of the hypospadias procedure, and opinions on the necessity of fellowship training. Data were analyzed for statistical differences with Wilcoxon rank sum and multiple and logistic regression tests.

RESULTS

Surveys were completed by 89 pediatric urologists and 208 urology residents or recent graduates (response rate 53% and 40%, respectively). Approximately 70% of residents and attending physicians report that less than 50% of the overall hypospadias procedure is performed by the resident. There appears to be agreement between residents and attending physicians regarding the perceived amount of resident participation for all steps of the procedure except glanular mobilization. Additionally, 71% of residents and 86% of attending physicians believe that a pediatric fellowship is necessary to perform hypospadias surgery.

CONCLUSIONS

The majority of residents and attending physicians report limited resident participation in hypospadias surgery. Residents and attending physicians have significant agreement on perceived participation. Our data do not corroborate the program data regarding the role of urology residents in hypospadias repair. The majority of residents and pediatric urologists believe specialized training is required to perform hypospadias surgery.

Quality assessment of hypospadias repair with emphasis on techniques used and experience of pediatric urologic surgeons

OBJECTIVES

To assess outcomes in hypospadias repair at our institution, as compared with the literature, with repair technique and surgeon considered as risk factors.

METHODS

The results of 299 primary hypospadias corrections were analyzed. All procedures were performed by three experienced pediatric urologists. Mean patient age at operation was 16.3 months. Follow-up was between 6 months and 5.5 years. Distal hypospadias repair was carried out in 242 patients, with tubularized incised plate reconstruction in 100 patients, advancement in 128, and the Mathieu technique in 14.

RESULTS

During follow-up, complications occurred overall in 93 patients (31%). For distal hypospadias complications occurred in 59 patients (24%). The most common findings for distal hypospadias were urethral fistulas (14.4%). The complication rate depended on the severity of the anomaly (0 glanular, 28% pericoronal, and 63% proximal) and the chosen technique (16% advancement technique versus 60% tubular techniques). We found statistically significant differences in complication rates between operating surgeons.

CONCLUSIONS

Complications after hypospadias surgery are frequent. They are multifactorial and depend mainly on the type of the anomaly, the chosen technique, and the experience of the surgeon. More studies are needed to obtain an internationally accepted quality indicator for the outcome of hypospadias repair.