Inconsistency among surgeons on classification of hypospadias - a survey using the CDC hypospadias atlas
Catherine Nguyen, MD1, Cassandra Gormley, BS2, Xiaoyi Shan, BS2, Beverly Spray, PhD2, Stephen Canon, MD1.
1Texas Children's Hospital, Houston, TX, USA, 2Arkansas Children's Hospital, Little Rock, AR, USA.
Background: Hypospadias is a common congenital malformation where the male urethral meatus opens ventral to the tip of the penis and can be found anywhere from the glans to the perineum. The estimated rate of hypospadias is 1/200 male births in the United States. There are several classification systems for hypospadias; however, the phenotypic subtypes of hypospadias are inconsistently reported on across databases due to the inherently subtle variability of the penile anatomy. Consistent classification of hypospadias would allow for more accurate data regarding etiological correlates of specific subtypes as well as perioperative care and surgical outcomes. The Center for Disease Control (CDC) published an online manual for birth defect surveillance which included a hypospadias atlas with photograph representation for different hypospadias phenotypic subtypes in order to more easily facilitate abstraction of hypospadias throughout the world. However, this atlas is not widely known or used as a reference amongst pediatric urologists. In this study, we sought to determine the consistency amongst surgeons who specialize in managing this condition on the classification of hypospadias using the CDC atlas.
Method: A questionnaire was developed using the photographs directly from the CDC atlas for hypospadias. Demographic data regarding geographical location and years in practice were also assessed. The survey was distributed via email to members of the Society for Pediatric Urology and American Association of Pediatric Urologists. Responses were anonymously collected.
Result: The survey was sent to 407 recipients and 166 responses were received. 95.8% of responders were from the United States, 3% from Canada, 0.6% from Brazil and 0.6% from Puerto Rico. 63.2% of responders had 16 or more years in practice after fellowship, 15.7% had 11-15 years, 14.5% had 6-10 years, 6.6% had 0-5 years in practice. Prior to the survey, 88.6% were not aware of the CDC hypospadias atlas. 93.4% of responses correctly identified glanular hypospadias, 56.6% correctly identified subcoronal, 3.6% correctly identified penile hypospadias, 54.2% correctly identified scrotal hypospadias, and 59% correctly identified perineal hypospadias (Figure 1).
Conclusion: Using the CDC hypospadias atlas, our survey showed that glanular hypospadias was most often correctly identified, while penile hypospadias was the least. The remaining subtypes were correctly identified by approximately half of the responders. Our result shows there is great variability in classification of hypospadias amongst members of pediatric urology societies, and thus a need for a standardized approach to hypospadias classification. Compared to the majority of references in the literatures, the CDC hypospadias atlas uses photographs of real anatomy which may serve as a more objective guideline for classifying hypospadias. There is potential benefit in refining this atlas for use in hypospadias management.
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