The Northeastern Society of Plastic Surgeons

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Initial Practice Pattern of Hypospadias Repair for a Solo Pediatric Urologist Starting Practice in a Middle Eastern Tertiary Care Center
Jad Degheili, MD1, Mohammed Shahait, MD2, Hani Tamim, PhD1, Rola Jaafar, PhD1, Rami Nasr, MD1, Yaser El-Hout, MD1.
1American University of Beirut Medical Center, Beirut, Lebanon, 2University of Pittsburg Medical Center, Pittsburg, PA, USA.

BACKGROUND: Hypospadias is a common pediatric urological anomaly, where its appropriate surgical management and favorable outcome are influenced by proper fellowship training. The scarcity of pediatric urologists and biased referral, may influence the practice pattern of a starting solo pediatric urologist , diverting it from expected norms in North American pediatric centers. This study aims to describe the initial practice pattern for a solo pediatric urologist in a Middle Eastern tertiary care center and its change over time.
METHODS:A retrospective analysis of a prospectively collected database of hypospadias repair for a single pediatric urologist was made. The first consecutive 120 repairs were analyzed. Age at presentation and meatal location and previous repairs (cripple status) were noted. Procedures were either primary urethroplasty (mainly TIP) or staged (preputial graft, buccal graft, 2nd stage urethroplasty). Outcome and follow-up were recorded. Evolution of practice over time was analyzed by 3 consecutive groups: Period 1,2 or 3 with (n=40) in each group. Data were entered and analyzed by SPSS version 24.Association between the different groups was carried out using the chi-squared or Fishers exact test for categorical variables whereas the independent t-test or ANOVA was used for continuous variables. A p-value <0.05 was used to indicate statistical significance.RESULTS:Median age at repair was 3.1 years (range 1.2-23 years).Only 72/120 (60%) presented without prior repair. Forty-eight (40%) had previous repairs (median 2 repairs, range 2-7 repairs).Twenty one (17.5%) presented as cripples. Of 120 repairs, meatal locations were 9 coronal, 32 subcoronal, 21 distal shaft, 15 midshaft, 11 proximal shaft, 20 penoscrotal, 10 scrotal and 2 perineal: 41 (34%) distal, 36 (30%) mid, 43 (36%) proximal. Looking into the three practice periods (each spent to repair 40 cases), repairs were performed over 24 months, 16 months and 12 months for Period 1,2, and 3, respectively (p=0.05). TIP repairs were done for 11 (27.5%), 17 (42.5%) and 22 (55%) for Period 1,2 and 3, respectively (p=0.04). Cripple presentations were 12(30%), 7 (17.5%) and 2 (5%) for Period 1,2 and 3 respectively ( p=0.05). First-stage buccal mucosa graft repairs decreased over periods: 7 (17.5%), 5 (12.5%) and 1 (2.5%) for Periods 1,2, and 3 respectively (p=0.05). In contrast, first-stage preputial graft repairs remained steady: 7 (17.5%), 7(17.5%) and 6(15%) , P-value NS. For all first-stage grafts, 30/31 (97%) had excellent graft take. All urethroplasties were 84 (50 TIP, 32 second-stage Thierch-Duplay, 2 GAP) with 3/84 (4%) fistulas that were all successfully repaired.
CONCLUSIONS: The studied practice pattern of hypospadias repair is different from a typical North American practice. There is a skew in the internationally expected quantity and quality of cases with a relative increase in proximal and complicated cases and decrease in distal straightforward cases and a relatively older age of presentation. As practice progresses, a normalization of the pattern is noted as seen in this study with increase in TIP repairs and decrease in cripple presentations and first stage buccal graft repairs. Nonetheless, outcomes, including graft take and fistula rate, remain comparable to a standard North American practice.


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