LATE PRESENTATION OF COMPLICATIONS AFTER HYPOSPADIAS REPAIR: IS FOLLOW-UP REGIMEN A CONTRIBUTING FACTOR?
Mark A. Faasse, MD, MPH, Dennis B. Liu, MD.
Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA.
Complications after primary hypospadias repair often present more than 1 year postoperatively. Factors that may contribute to the late presentation of complications have yet to be investigated. Follow-up regimen is one potential contributing factor, as patients with fewer or less frequent follow-up visits are subjected to less scrutiny, and recognition of complications may be delayed. This study aims to characterize and compare the follow-up regimens of patients with late- and early-presenting complications.
Boys who underwent surgery at our institution for complications after hypospadias repair from 2011-2013 were retrospectively identified. The type of primary repair and the time elapsed between the initial surgery and the date at which each complication was diagnosed were determined. Late complications were defined as having presented more than 1 year after primary repair; all others were designated as early.
The date of each patient’s most recent encounter prior to presentation of their complication(s) was noted, and the follow-up intervals during which complications emerged were compared between early and late complications. Patients’ age at presentation of their complication(s) and their prescribed (vs. actual) follow-up regimens were also compared.
A total of 57 hypospadias complications were repaired in 51 patients. 18 patients (35%) had late complications (see Table). Complications after a midshaft or distal hypospadias repair were more likely to present late than complications after a 1- or 2-stage proximal repair (59% vs. 31% vs. 6%, respectively; p = 0.003). The median interval between encounters during which late complications emerged was 24 (IQR, 16-43) months, compared to 1.2 (0.7-2.2) months for early-presenting complications (p < 0.001).
Prior to the visit at which their complication was diagnosed, 9 of the 18 patients (50%) with late complications did not have an encounter beyond 2 months postoperatively. Late complications tended to present at toilet-training age, with 13 of the 18 patients being between 2-4 years-old (median, 3.5 years; IQR, 2.6-5.6).
Patients with late complications were more likely to have received instructions for follow-up either PRN (p = 0.02) or after a significantly longer time interval (p = 0.006) at their previous encounter. The difference between prescribed and actual follow-up intervals was also significantly greater in patients with late complications (p = 0.001).
Late complications after hypospadias repair typically emerge during a lengthy follow-up interval. When this occurs, the precise point at which the complication developed is unknown, as it may have gone unrecognized for some time. Adherence to a more structured follow-up regimen would clarify the true incidence of late-occurring complications and may reduce late presentation, especially among patients with midshaft or distal primary repairs. Earlier diagnosis would allow secondary procedures to be completed earlier.
Table. Comparison of Early (≤ 12 mos.) vs. Late (> 12 mos.) Complications after Hypospadias Repair
|No. complications / patients||36 / 33||21 / 18||n/a|
|Type of primary repair, no. patients (% row)||Midshaft/distal (1-stage)||9 (41)||13 (59)||0.003|
|Proximal 1-stage||9 (69)||4 (31)|
|Proximal 2-stage||15 (94)||1 (6)|
|Follow-up interval (mos.) in which complications emerged, median (IQR)||1.2 (0.7-2.2)||24 (16-43)||< 0.001|
|Age (mos.) at presentation of complications, median (IQR)||17 (12-22)||42 (31-67)||< 0.001|
|Prescribed follow-up prior to presentation of complications||PRN, n (% col)||2 (6)||6 (33)||0.02|
|Specified, n (% col)||31 (94)||12 (67)|
|Specified interval (mos.), median (IQR)||1.5 (1-1.5)||12 (1.5-24)||0.006|
|Difference (mos.) between prescribed and actual follow-up intervals, median (IQR) (n=43)||0.2 (0.1-0.8)||11 (4.6-15)||0.001|
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