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Should contemporary urology residents expect to be able perform hypospadias repair when they graduate without fellowship training? Results from a survey of SPU membership.
John Michael Masterson, MD1, Michael Zaliznyak, BA2, Aurash Naser-Tavakolian, MD1, Peris R. Castaneda, MD1, Andrew L. Freedman, MD1.
1Cedars-Sinai Medical Center, Los Angeles, CA, USA, 2St. Louis University School of Medicine, Los Angeles, CA, USA.

Background
As surgical training has become increasingly subspecialized, residents have been encouraged to pursue additional fellowship training. We sought to better understand current attitudes regarding expectations for competency for non-fellowship trained graduates in sub-specialty procedures and how this has affected teaching practices during residency training. We chose to study hypospadias as a model as it is a signature procedure for pediatric urologists that is both technically challenging and at the same time quite common.
Methods
We created a survey tool utilizing the well-established Zwisch scale (Figure 1) to assess the level of autonomy afforded to trainees during various types of hypospadias repair as well as elicited attitudes regarding post-training expectations. Our survey was distributed via email to the Society of Pediatric Urology (SPU) membership. Additionally, we collected respondent demographic data such as geographic location, years in practice, and practice setting.
Results
A total of 178 of 761 (23%) SPU members completed the survey. We excluded 6 respondents who are retired or do not perform hypospadias repair. Demographic results are outlined in Table 1. Of the 172 included respondents, 170 (99%) felt that trainees should not perform hypospadias repair independently in practice without additional fellowship training. Among pediatric urologists who train residents, trainee autonomy as measured by the Zwisch scale was limited to an assistant role for the vast majority of trainees and decreased as the severity of the hypospadias increased (Figure 2).
Conclusions
Urology residents for the most part are not being afforded a level of autonomy in hypospadias cases during training that would suggest competency for independence following graduation. Additionally, there is a dramatic degree of consensus that contemporary graduates are not expected to be competent to perform hypospadias repair in independent practice without additional fellowship training. This raises the question if there are other common sub-specialty procedures in urology where residents are not expected to achieve competence, and if so, how should we as educators, be forthcoming about the limitations of urology residency training to set appropriate trainee and employer expectations?
Table 1. Respondent characteristics.

N%
Total172100%
AUA section
Mid-Atlantic Section159%
New England Section85%
New York Section95%
North Central Section3219%
Northeastern Section127%
South Central section2917%
Southeastern Section6638%
Western Section11%
Respondent position titles*
Department Chair73%
Division Chair3416%
Residency Program Director2311%
Pediatric Urologist15269%
Adult Urologist31%
Respondents' trainee profile
Residents9253%
Fellows00%
Both6236%
Neither1810%
Respondent practice setting*
Academic12450%
Private3113%
Hospital affiliated3313%
Children''s hospital5924%
Years in practice
1-10 years5431%
11-20 years4526%
21+ years7342%
Respondents performing hypospadias repair
Yes172100%
No00%
Should graduating residents perform hypospadias repair without fellowship training?
Yes21%
No17099%
*Multiple responses allowed were allowed for these items.

Figure 1. The Zwisch scale.


Figure 2. Trainee autonomy by hypospadias repair type as measured by the Zwisch scale.


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