Practice patterns in the care of proximal hypospadias among pediatric urologists.

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.