BACKGROUND: Standardization of hypospadias care within an institution, let alone nationally or globally, remains an elusive task. The seemingly limitless array of surgical techniques, lack of universal phenotype definition, and wide variability in hypospadias anatomy make this difficult. Recent literature has suggested that some distal hypospadias patients may be at a higher risk for complication based on glanular anatomy. We hypothesized that in patients with distal hypospadias with a flat, unfavorable or intermediate glans groove performing a dorsal inlay graft (DIG) would decrease complications versus a Thiersch Duplay (TD). Then we leveraged our electronic medical record (EMR) to create a novel alert/nudge tool to help providers recognize high-risk patients at the time of initial visit and suggest a DIG repair.
METHODS: We retrospectively reviewed our hypospadias database for patients from 2016 to 2023 who underwent primary distal hypospadias repair and had a flat, unfavorable or intermediate glans groove at the time of surgery. We collected clinicodemographic information as well as data on surgeon, surgical repair type, complication type, follow-up, testosterone administration, glans width, glans groove, length of urethroplasty, and chordee. We analyzed the incidence of post operative complications in patients that underwent a DIG vs TD repair. We then performed a COX proportional hazard model to assess the effect of predictors on time to complication.
RESULTS: 213 distal hypospadias patients met criteria and underwent repair; 40/213 (19%) DIG and 173/213 (81%) TD. Median age at surgery was 9 months. DIG patients were given preoperative testosterone more often (p=0.02), more often had an unfavorable glans groove, (p<0.001), and were more often operated on by surgeons with less than 10 years of practice (65% vs 45%, p = 0.03) than patients that had a TD repair. There was no significant difference in glans width at the time of surgery between the two groups (15.2mm DIG, 15.6mm TD; p=0.4). The complication rate for DIG was significantly lower than for TD repairs (2.5% vs.18%, respectively; p=0.01). COX regression identified a hazard ratio of 6.45, indicating a higher risk of complication for TD over DIG. Given the improved clinical outcomes in this higher risk phenotype, we developed a novel automated nudge tool based on anatomic variables in our EMR, guiding consideration for DIG at the time of surgery.
CONCLUSIONS: In distal hypospadias patients with higher risk anatomy, specifically a narrow and flattened glans groove, DIG resulted in improved surgical outcomes compared to Thiersch Duplay repair. Identification of higher risk hypospadias phenotypes and technical modification during repair are key to individualizing hypospadias care and improving outcomes. Our novel automated EMR nudge tool integrates phenotypic hypospadias characteristics to help guide surgical decision making.
