Identifying variability in surgical practices and instrumentation for hypospadias repair across the Western Pediatric Urology Consortium (WPUC) network
Justine R. Yamashiro, BS, MBA1, J. Christopher Austin, MD2, Luis H. Braga, MD, PhD3, Kai-Wen Chuang, MD4, Carol A. Davis-Dao, PhD4, Sarah Hecht, MD2, Sarah A. Holzman, MD4, Antoine E. Khoury, MD4, Eric A. Kurzrock, MD5, Steven E. Lerman, MD1, Melissa McGrath, BASc3, Paul A. Merguerian, MS, MD6, Amanda F. Saltzman, MD7, Anthony J. Schaeffer, MPH, MD8, Casey Seideman, MD2, Jennifer S. Singer, MD1, Peter Wang, MEd, MD9, Elias J. Wehbi, MD4, Hsi-Yang Wu, MD10, Renea M. Sturm, MD1.
1University of California Los Angeles, Los Angeles, CA, USA, 2Oregon Health & Science University, Portland, OR, USA, 3McMaster University, Hamilton, ON, Canada, 4University of California Irvine, Irvine, CA, USA, 5University of California Davis, Sacramento, CA, USA, 6University of Washington, Seattle, WA, USA, 7University of Kentucky, Lexington, KY, USA, 8University of Utah, Salt Lake City, UT, USA, 9LHSC-Victoria Hospital, London, ON, Canada, 10Brown University, Providence, RI, USA.
Background The tubularized incised plate (TIP) urethroplasty procedure has rapidly become the most common hypospadias repair performed worldwide due to its low complication rates and favorable cosmetic and functional outcomes. Modifications of the original TIP have been described and associated with significantly decreased complication rates in single center series. However, broader analyses of best technical practices for hypospadias repair remain limited. We hypothesized that wide technical variability exists, particularly in the urethroplasty and glansplasty portions of hypospadias repairs. With the eventual goal of developing a surgical atlas of hypospadias repair techniques, this study examined 1) common language used in operative report templates and 2) surgical technical details for two common procedures, tubularized incised plate (TIP) distal and proximal hypospadias repairs across a multi-institutional surgical network.
Methods A two-part study was completed. First, a survey was distributed to the network to assess surgeon volume and methods of recording hypospadias repair operative notes. Subsequently, an operative template or a representative de-identified operative note describing a TIP and/or proximal repair with urethroplasty was obtained from participating surgeons. Each template or note was analyzed for natural language that signified specified portions of the procedure. Procedural details from each note were tabulated and confirmed with each surgeon, clarifying that the recorded findings reflected their current practice for each of the following: suture type, needle, and technique for each layer of the urethroplasty and glansplasty, tissue selection for the urethroplasty and secondary coverage, and urethral catheter (IRB #21-000800).
Results Twenty-five surgeons from 9 institutions completed the survey. The number of primary distal hypospadias repairs performed per surgeon in the past year ranged from 1-10 to >50, with 40% performing 1-20. Primary proximal hypospadias repairs performed in the past year ranged from 1-30, with 60% performing 1-10. 96% of surgeons maintain operative notes within an electronic health record. Of these, 66.7% edited a template as their primary method of note entry; 76.5% of these surgeons reported that the template captures their operative techniques very or moderately well. Operative notes or templates from 16 surgeons at 10 institutions were analyzed: 14 TIP and 7 proximal hypospadias repairs. Highlights of recorded and verified data elements are demonstrated in the attached tables for proximal and TIP procedures.
Conclusions Wide variability in technical surgical details of categorically similar hypospadias repairs was observed across a large surgical network. This project is a first step toward creation of an atlas of descriptive terminology and techniques used in hypospadias repair. As a future direction, natural language processing enabled algorithms may be applied to rapidly identify these common data elements from operative notes. Additionally, data gleaned from this study will provide important variables for future surgical studies of hypospadias outcomes. 
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