Disparities in the follow-up and presence of complications after distal hypospadias repair
Alexandra R. Siegal, MD1, Leah Beland, MD2, Nathan Hyacinthe, BS3, Christopher J. Long, MD3, Mark R. Zaontz, MD3, Karl Godlewski, MD3, Dana A. Weiss, MD3, Jason Van Batavia, MD3, Emily Ai, MD3, Christopher Moran, MD3, Aseem R. Shukla, MD3, Arun K. Srinivasan, MD3, Sameer Mittal, MD3, Steven A. Zderic, MD3, Thomas F. Kolon, MD3, Katie M. Fischer, MD3.
1Icahn School of Medicine at Mount Sinai, New York, NY, USA, 2Northwell, Manhasset, NY, USA, 3Children’s Hospital of Philadelphia, Philadelphia, PA, USA.
Background:Complications after hypospadias repairs can negatively impact voiding and sexual function, typically resulting in additional surgical interventions. Anatomic and technical factors have been identified that contribute to complications; however, the impact that social determinants of health have on outcomes remains unclear. We hypothesized that the presence of complications following distal hypospadias repair in children is associated with socioeconomic opportunity.Methods:We performed a retrospective analysis of children ≤18 years who underwent single-stage distal hypospadias repair at a tertiary children’s hospital from January 2016 to December 2022. Patients with <30 days follow-up were excluded from the primary analysis. Demographic data and surgical characteristics were recorded. The COI (Childhood Opportunity Index) was used as a measure of the quality of resources and conditions present in a community necessary for a child to develop in a healthy way; this was calculated for each patient based on their residential address. The primary outcome was the presence of post-operative complications and the association of complications with COI. The secondary outcome was the association of COI and race with being lost to follow up (defined as <30 days of follow-up post-operatively). Univariate and multivariable logistic regression analyses were used to assess the association of complications with COI as well as anatomic and technical factors.Results:772 patients met inclusion criteria with demographic data in Table 1. The surgical complication rate was 9.3% (overall complication rate was 14.1%). Fistula was the most common surgical complication (5.4%) followed by meatal stenosis (2.1%). 6.5% of patients had cosmetic complications such as skin bridges or inclusions cysts, of which 1.7% underwent correction. There was no significant difference in COI and its subcategories of education, health/ environment, and social/ economic, nor race or language between patients who developed complications and those who did not (Table 1, p>0.05). Glans width, degree of chordee, and repair type were associated with complications on univariate regression analysis (p<0.01) and glans width and degree of chordee were also significant on multivariate analysis (p<0.01) whereas COI was not significant on either univariate or multivariate analysis. When comparing those with follow-up to those without, significantly more non-white race patients and those with a lower COI (overall and in all subcategories) were lost to follow-up (Table 2, p<0.01). Conclusions:We found that socioeconomic opportunity is not an independent risk factor for complications after distal hypospadias repair. Instead, complications appear to be impacted by anatomic factors and repair type. However, it is important to note that children with a lower opportunity index were more likely to be lost to follow-up, and that complication data amongst this group may be underreported. For all complications to be addressed, distinct efforts should be made to identify at-risk children and minimize barriers to follow-up.
| Table 1: Patient demographics by Complication Status | ||||
| No complication (n=663) | Complication(n=109) | p-value | ||
| Age at time of surgery (months), median (IQR) | 9 (7, 12) | 8 (7, 12) | 0.14 | |
| Patient Race | 0.67 | |||
| White | 399 (60.2%) | 68 (62.4%) | ||
| Black/ African American | 99 (14.9%) | 18 (16.5%) | ||
| Asian | 31 (4.7%) | 3 (2.8%) | ||
| Indian | 9 (1.4%) | 1 (0.9%) | ||
| Native Hawaiian/ Pacific Islander | 1 (0.2%) | 1 (0.9%) | ||
| Refused | 7 (1.1%) | 0 (0.0%) | ||
| Other | 117 (17.6%) | 18 (16.5%) | ||
| Primary English Speaking | 644 (97.1%) | 104 (95.4%) | 0.37 | |
| Overall COI Level | 0.37 | |||
| 1 | 90 (13.6%) | 10 (9.2%) | ||
| 2 | 56 (8.4%) | 8 (7.3%) | ||
| 3 | 87 (13.1%) | 18 (16.5%) | ||
| 4 | 147 (22.2%) | 31 (28.4%) | ||
| 5 | 283 (42.7%) | 42 (38.5%) | ||
| Education COI | 0.26 | |||
| 1 | 94 (14.2%) | 10 (9.2%) | ||
| 2 | 71 (10.7%) | 10 (9.2%) | ||
| 3 | 73 (11.0%) | 16 (14.7%) | ||
| 4 | 122 (18.4%) | 27 (24.8%) | ||
| 5 | 303 (45.7%) | 46 (42.2%) | ||
| Health & Environment COI | 0.23 | |||
| 1 | 80 (12.1%) | 10 (9.2%) | ||
| 2 | 94 (14.2%) | 22 (20.2%) | ||
| 3 | 119 (17.9%) | 24 (22.0%) | ||
| 4 | 182 (27.5%) | 22 (20.2%) | ||
| 5 | 188 (28.4%) | 31 (28.4%) | ||
| Social & Economic COI | 0.15 | |||
| 1 | 87 (13.1%) | 12 (11.0%) | ||
| 2 | 55 (8.3%) | 5 (4.6%) | ||
| 3 | 97 (14.6%) | 21 (19.3%) | ||
| 4 | 153 (23.1%) | 34 (31.2%) | ||
| 5 | 271 (40.9%) | 37 (33.9%) | ||
| Table 2: Patient Demographics by Follow Up Status | ||||
| Sufficient Follow Up (n=772) | Follow Up <30 days (n=166) | p-value | ||
| Age at time of surgery (months), median (IQR) | 9 (7, 12) | 9 (7, 15) | 0.11 | |
| Follow Up (months), median (IQR) | 8.515068 (3.221918, 26.81096) | .230137 (.0986301, .3616439) | <0.001 | |
| Patient Race | <0.001 | |||
| American Indian/ Alaska Native | 0 (0.0%) | 1 (0.6%) | ||
| Asian | 34 (4.4%) | 6 (3.6%) | ||
| Black/ African American | 117 (15.2%) | 46 (27.7%) | ||
| Indian | 10 (1.3%) | 1 (0.6%) | ||
| Native Hawaiian/ Pacific Islander | 2 (0.3%) | 0 (0.0%) | ||
| Other | 135 (17.5%) | 26 (15.7%) | ||
| Refused | 7 (0.9%) | 5 (3.0%) | ||
| White | 467 (60.5%) | 81 (48.8%) | ||
| COI | <0.001 | |||
| 1 | 100 (13.0%) | 46 (27.7%) | ||
| 2 | 64 (8.3%) | 16 (9.6%) | ||
| 3 | 105 (13.6%) | 32 (19.3%) | ||
| 4 | 178 (23.1%) | 32 (19.3%) | ||
| 5 | 325 (42.1%) | 40 (24.1%) | ||
| Education COI | <0.001 | |||
| 1 | 104 (13.5%) | 45 (27.1%) | ||
| 2 | 81 (10.5%) | 19 (11.4%) | ||
| 3 | 89 (11.5%) | 19 (11.4%) | ||
| 4 | 149 (19.3%) | 33 (19.9%) | ||
| 5 | 349 (45.2%) | 50 (30.1%) | ||
| Health and Environment COI | <0.001 | |||
| 1 | 90 (11.7%) | 38 (22.9%) | ||
| 2 | 116 (15.0%) | 33 (19.9%) | ||
| 3 | 143 (18.5%) | 35 (21.1%) | ||
| 4 | 204 (26.4%) | 32 (19.3%) | ||
| 5 | 219 (28.4%) | 28 (16.9%) | ||
| Social and Economic COI | <0.001 | |||
| 1 | 99 (12.8%) | 46 (27.7%) | ||
| 2 | 60 (7.8%) | 20 (12.0%) | ||
| 3 | 118 (15.3%) | 29 (17.5%) | ||
| 4 | 187 (24.2%) | 33 (19.9%) | ||
| 5 | 308 (39.9%) | 38 (22.9%) | ||
| Surgery Duration (minutes), median (IQR) | 106 (78, 137) | 91.5 (60, 123) | <0.001 | |
| Chordee Severity | 0.012 | |||
| None | 220 (28.5%) | 68 (41.0%) | ||
| Glans tilt/ <15 degrees | 84 (10.9%) | 22 (13.3%) | ||
| Mild (15-30 degrees) | 170 (22.0%) | 31 (18.7%) | ||
| Moderate (30-45 degrees) | 129 (16.7%) | 24 (14.5%) | ||
| Severe (>45 degrees) | 166 (21.5%) | 21 (12.7%) | ||
| Unknown | 3 (0.4%) | 0 (0.0%) | ||
| Type of Repair | 0.018 | |||
| GAP | 15 (1.9%) | 7 (4.2%) | ||
| MAGPI/MIV | 265 (34.3%) | 73 (44.0%) | ||
| Mathieu | 6 (0.8%) | 0 (0.0%) | ||
| Island Onlay | 53 (6.9%) | 4 (2.4%) | ||
| TIP | 13 (1.7%) | 0 (0.0%) | ||
| Thiersch Duplay | 395 (51.2%) | 79 (47.6%) | ||
| DIG | 24 (3.1%) | 3 (1.8%) | ||
| Barcat | 1 (0.1%) | 0 (0.0%) | ||
| Urethroplasty Length, median (IQR) | 9 (6, 12) | 8 (6, 12) | 0.42 | |
| Testosterone | 220 (28.5%) | 42 (25.3%) | 0.45 | |
| Primary English Speaking | 748 (96.9%) | 159 (95.8%) | 0.47 | |
| Glans Width, median (IQR) | 15 (13, 17) | 15 (13, 17) | 0.85 | |
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