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Practice patterns in the care of proximal hypospadias among pediatric urologists
James T Rague1, Ilina Rosoklija1, David I Chu1
1Division of Urology, Ann and Robert H. Lurie Children's Hospital of Chicago, USA.
Insights
Pediatric urologists show varied approaches to proximal hypospadias care, with inconsistent pre-operative evaluations and referrals. Surgeon volume does not significantly impact these practice patterns, highlighting a need for standardized guidelines.
Area of Science:
- Pediatric Urology
- Genitourinary Surgery
- Developmental Biology
Background:
- Proximal hypospadias, affecting 25% of cases, often involves genetic factors or differences in sex development (DSD).
- High surgical complication rates and variable practice patterns underscore the need for consensus in managing this condition.
- Understanding current management variability is crucial for developing standardized care recommendations.
Purpose of the Study:
- To evaluate the medical and surgical management practices of pediatric urologists for proximal hypospadias.
- To identify variations in diagnostic testing and referral patterns among specialists.
- To explore the influence of surgeon case volume on practice patterns.
Main Methods:
- An anonymous web-based survey was distributed to members of the Societies for Pediatric Urology.
- The survey collected data on medical and surgical management practices for proximal hypospadias.
- Statistical comparisons were made between high-volume (>50th percentile) and low-volume (≤50th percentile) surgeons.
Main Results:
- 125 pediatric urologists completed the survey, predominantly practicing in urban academic settings.
- Most respondents infrequently referred patients to other specialists or received referrals for surgical care.
- Karyotype ordering was common, while hormonal and advanced genetic testing were less frequent; systematic post-operative data collection was rare.
- High-volume surgeons reported receiving more referrals and performing more independent surgeries, but lab testing and referral practices showed no significant differences between volume groups.
Conclusions:
- Practice patterns for proximal hypospadias management, particularly pre-operative medical evaluation, vary significantly among pediatric urologists.
- Surgeon operative volume had minimal impact on diagnostic testing and referral practices.
- Greater uniformity in the management of proximal hypospadias is achievable and necessary, with clinical practice guidelines potentially improving care quality.
Introduction:
About 25 % of patients with hypospadias have a proximal form, often associated with an underlying genetic cause or difference of sex development (DSD). Surgical complication/re-operation rates are high, surgical practice patterns are variable, and consensus recommendations to guide medical and surgical management are not yet available. One presumed barrier to consensus is understanding variability in management for this condition.
Objective:
To assess medical and surgical practice patterns of pediatric urologists regarding care of proximal hypospadias.
Study Design:
An anonymous, web-based survey was sent to members of the Societies for Pediatric Urology to capture medical and surgical management practices for patients with proximal hypospadias. Respondent demographics were obtained. Median estimated patients cared for per year was determined. Comparisons between those ≤50th percentile for volume and >50th percentile were made using chi squared and Fisher's exact tests.
Results:
137 completed surveys were returned (137/311 (44 %) opened emails), and 125 responses met inclusion criteria. Respondents were predominantly male (70 %), and practice in an urban (85 %), academic (72 %) setting. The median (IQR) estimated number of patients cared for per year was 7 (5.0, 10.0). Half (50 %) never receive referrals from other pediatric urologists for surgical care. Most never refer patients to other surgeons within (55 %) or outside (72 %) of their practice. Frequent independent ordering of a karyotype was reported, with less frequent ordering of hormonal and advanced genetic testing (Table). Performing systematic, post-operative data collection was reported infrequently (37 %). Those >50th percentile in volume compared to those ≤50th percentile reported receiving more referrals from other urologists for surgical care (any referrals received, 66 % vs 36 %, p = 0.001) and more commonly perform surgery independently (63 % vs 32 %, p = 0.003). There were no differences between groups regarding lab testing, medical specialty referrals, or surgical management.
Discussion:
Proximal hypospadias surgery is uncommonly performed by most pediatric urologists and patterns of independent lab evaluation and referral to medical subspecialities are variable. Few differences in practice were seen based on surgeon volume, especially around lab testing and medical specialty referrals. Though an optimal approach to medical evaluation is not yet defined, opportunities for greater uniformity in the management of proximal hypospadias exist. Clinical practice guidelines to help surgeons determine the best approach to medical evaluation and surgical management could improve quality of care in proximal hypospadias.
Conclusions:
The approach to pre-operative medical care of patients with proximal hypospadias varies among pediatric urologists and is largely independent of surgeon operative volume.
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