Diversity of Approaches to Hypospadias Repair and Its Perioperative Management
Jennifer E. Reifsnyder, MD1, Lane S. Palmer, MD2.
1Cohen Children's Medical Center, Glen Oaks, NY, USA, 2Cohen Children's Medical Center, New Hyde Park, NY, USA.
BACKGROUND: There is currently no standard of care in many aspects of hypospadias management. We sought to determine whether there was a consensus among pediatric urologists on questions of surgical technique and perioperative care.
METHODS: An anonymous online survey was sent to practicing members of the Societies for Pediatric Urology. The survey aimed to capture data regarding approaches to hypospadias repair and management, including anesthetic considerations, catheter placement, choice of dressing, and postoperative antibiotic treatment. RESULTS: The survey was completed by 133 of 385 pediatric urologists (34.5%). 54 (40.6%) had been in practice for >20 years. The majority practice only pediatric urology (79.7%) and completed formal training (89.5%). Hypospadias repair was overwhelmingly recommended between ages 6-12 months (89.5%). Most surgeons (85.7%) typically work with a pediatric anesthesiologist and a block (caudal, penile, pudendal, spinal) is performed nearly universally (96.2%). Most (70.7%) typically offer outpatient distal repair, while fewer perform outpatient staged repairs (47.4%) or redo surgery (33.8%). Urethroplasties are done largely with VicrylTM/DexonTM (50.4%) or MaxonTM/PDSTM (48.1%), and while the majority use 7-0 suture (73.7-75.9% based on severity), 21.1-24.1% use 6-0. Urethral stenting for glanular repairs was split: 53.4% leave a stent but 46.6% do not. Stent choice varied as 40.4% use a feeding tube and 27.6% use a Firlit/Zaontz stent; stent duration was longer for more proximal repairs. Dressing choice (compressive vs. noncompressive) varied, but 50.9% use a noncompressive dressing, while 24.1-39.8% use a compressive dressing, depending on severity; some use no dressing (22.6% for glanular repairs, 7.5% for distal, 3.8% for mid-proximal shaft). On average, 40.6% leave a dressing for 1-3 days, while 36.3% leave it for 4-7 days. On average, 42.4 % allow bathing within 1-3 days, while 31.3% recommend waiting 4-7 days. Most surgeons prescribe postoperative antibiotics, regardless of severity (60.9% after distal repair, 70.9% after proximal, second stage, or hypospadias cripple repair). The majority (72.9%) prescribe narcotics for analgesia.
CONCLUSIONS: Approaches to hypospadias repair are extremely varied. Respondents were split with regard to type and duration of urethral stent and dressing, type of suture for urethroplasty, and inpatient versus outpatient repair for more severe cases. A substantial minority of pediatric urologists does not prescribe antibiotics or narcotic pain medications. Our results indicate the array of acceptable options for management of hypospadias.
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