Society For Pediatric Urology

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What Surgeon Stakeholders Should Be Engaged To Optimize Care for Female Patients with DSD?
Kristina D. Suson, M.D., Yegappan Lakshmanan, M.D., Janae Preece, M.D..
Children's Hospital of Michigan, Detroit, MI, USA.

BACKGROUND: In 2017, the Society of Pediatric Urology formed a task force to address issues surrounding the care of patients born with Disorders of Sex Development (DSD) or intersex, in response to a report released by the Human Rights Watch. Other physician stakeholders identified in their response to the report include endocrinology and pediatric/adolescent gynecology. We hypothesize that surgical subspecialties besides pediatric urology perform reconstruction for children with DSD and sought to characterize those procedures.
METHODS: The NSQIP-Pediatric database was queried regarding female DSD reconstructive surgeries performed between 2012 and 2016 using two codes: clitoroplasty for intersex (56805) and vaginoplasty for intersex (57335). Patients identified as “male” were excluded. We sought to compare patients undergoing surgery by pediatric urology and those undergoing surgery by other services with regards to surgical indications, operative data, and short-term outcomes. Data points included surgeon specialty, patient demographics, indication for surgery, concomitant procedures, and 30-day outcomes.
RESULTS: A total of 177 patients met inclusion criteria. Of those, 82.5% of surgeries were performed by pediatric urology (PURO), while 17.5% were performed by other services (nonPURO: 11.3% pediatric surgery, 4.0% urology, 2.3% gynecology). 32% of patients underwent both procedures in one setting; PURO was more likely than nonPURO to perform both procedures at once (37.0% vs 9.7%, p=0.003). In general, PURO was more likely to perform additional procedures during the same anesthetic (1 additional: 80.1% vs 64.5%, 2 additional: 54.1% vs 32.3%, 3 additional: 26.7% vs 9.7%, >3 additional: 25.3% vs 6.5%; p=0.024). The top surgical indications are presented in the Table. There was no difference in mean patient age (1981.6±175.6 days PURO vs 2652.8±382.6 nonPURO, p=0.118) or ASA class (p=0.233). Operative times tended to be longer for PURO patients than nonPURO patients (mean 220.6±10.7 vs 165.5±28.1 minutes, p=0.075). There was no difference in mean lengths of stay (2.6±0.3 days PURO vs 3.0±0.9 nonPURO, p=0.660). While there was no difference in overall complication rates (3.4% PURO vs 9.7% nonPURO, p=0.147), those undergoing surgery with nonPURO were more likely to develop post-operative urinary tract infections (1.4% vs 9.7%, p=0.038). There was no difference in readmission rate (4.8% PURO vs 3.2% nonPURO, p=1) or reoperation rate (2.7% PURO vs 3.2% nonPURO, p=1) between the groups.
CONCLUSIONS: Pediatric urologists perform most surgeries in female patients with DSD, but 17.5% of primary female DSD procedures were performed by specialties other than pediatric urology, most commonly pediatric general surgery. PURO more commonly performed additional procedures at the time of surgery, and more frequently combined vaginoplasty and clitoroplasty than nonPURO. Surgical indications and short-term outcomes were similar between patients undergoing surgery by PURO and those performed by nonPURO, although nonPURO patients had more post-operative urinary tract infections. All specialists that perform surgery for patients with DSD, including pediatric general surgeons and adult urologists, need to be engaged for optimal care for these complex patients.
Table: Most Common Indications for Clitoroplasty and Vaginoplasty
Pediatric Urology (PURO)%Other Specialties (nonPURO)%
Adrenogenital disorders43.1Adrenogenital disorders12.9
Indeterminate sex and pseudohermaphroditism13.7Indeterminate sex and pseudohermaphroditism12.9
Clitoral hypertrophy/malformation6.2Vaginal stricture/atresia9.7
Vaginal stricture/atresia4.8Other congenital anomalies of cervix, vagina, and external female genitalia6.5
Other specified bladder anomalies2.0Other specified anomalies of genital organs6.5
Other unspecified anomalies of genital organs6.5

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