Discrepant rates of hypospadias surgical complications
Hans Pohl, MD1, Md Sohel Rana, MBBS, MPH1, Bruce M. Sprague, BS1, Matthew Beamer, MD2, H. Gil Rushton, MD1.
1Children's National Medical Center, Washington, DC, USA, 2Georgetown University School of Medicine, Washington, DC, USA.
Background: Hypospadias repair is successful when the patient voids while standing with laminar flow, achieves satisfactory sexual intercourse with a straight penis, and has a slit-like orthotopic meatus on the tip of the glans. Complications include urethrocutaneous (UC) fistulae, diverticula, meatal stenosis, strictures, residual chordee and glans dehiscence. Complication rates have been reported to be as low as 5-10% following distal repair and up to 12-23% for proximal repairs. However complication rates may be greater than reported, particularly for proximal hypospadias. A wide discrepancy has been noted in hypospadias repair complication rates reported in the recent peer-reviewed literature compared with other reporting platforms such as the US News and World Reports (USNWR). Materials and Methods: We interrogated the Pediatric Health Information System (PHIS) database for males <18 years at time of hypospadias repair between January 1, 2010 and December 31, 2016. Index and revision procedures were sought by CPT codes for distal and proximal hypospadias repair. To evaluate the appropriateness of USNWR code list to identify revisions, we established 3 CPT groups defined as codes sought for by USNWR (Group A), the USNWR codes and codes for acquired UC fistula in males (Group B) and USNWR codes and UC fistula codes and any revision codes associated with the index procedures (Group C). To evaluate the appropriateness of USNWR follow-up interval of up to 36 months, we assessed revision rates with ever increasing follow-up intervals up to 7 years. The yearly revision rates over 5 years from each of 29 hospitals was summarized by the median and quantile regression with robust and clustered standard errors was used (Stata version 15.1 MP, Stata Corporation, Texas) to correlate whether the median revision rates changed significantly whether enhanced code lists or increased follow-up were used. Results: For the entire cohort of 29 hospitals, the average rate (sum of 29 mean rates/29 hospitals) for Group A was 3.32% (range: 0.48 - 7.36%) and 12.29% (range: 3.48 - 36.36%), for distal and proximal hypospadias repairs, respectively. The revision rate increases significantly from the USNWR (group A) by inclusion of a more expansive list of CPT codes associated with revision procedures (group B and C) in distal hypospadias. For proximal, this difference is not significant when comparing group A vs. B, but it is significant when comparing group A vs. C. For both distal and proximal hypospadias, the median revision rates increase with longer follow-up from 3 years to 7 years, and for all three groups; however, the upward trend is not statistically significant. The median time to revision for distal and proximal hypospadias was 1 year (range 0.75 - 1.91 years) and 1.08 years (range, 0.88 - 1.67 years), respectively. Conclusions: The CPT codes used to identify complications rather than duration of follow-up is the more likely variable affecting the rate of hypospadias complications. Our data show that increasing the observation period beyond 3 years does iidentify patients with late complications although these represent a smaller proportion of the total number requiring revision.
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