A 10-step procedure for distal hypospadias repair with 50% resident involvement is safe and effective

Abstract

Background: Pediatric urological surgeons have long recognized hypospadias repair to be technically challenging. Resident involvement during hypospadias repair is reportedly limited due to this perceived difficulty. Objective: To 1) describe a consistent 10-step streamlined surgical technique where senior urology residents perform half of a distal hypospadias repair 2) report outcomes of these procedures 3) review current literature regarding resident involvement in hypospadias repair. Subjects and methods: A retrospective analysis was performed for 147 patients who underwent distal hypospadias repair between July 2008 and July 2019 at an academic tertiary center children's hospital. Hypospadias repairs were included for one-stage procedures with a mid-penile or distal meatal location. A systematic literature review was conducted to search for articles regarding resident experiences in hypospadias repair and used for comparing outcomes. Surgical procedure and measurements: The surgery was performed with a variation of the TIP technique, which was divided into 10-steps with equal resident and attending participation. Complications were significant if they required additional surgical intervention. Results: Average patient age was 19.5 months with an average follow-up of 18.4 months. Overall, nine patients (6.1%) developed complications that required surgical reintervention. Urethrocutaneous fistula occurred in 5 (3.4%). Meatal stenosis developed in 3 (2.0%). One patient developed a skin tag (0.7%). These were comparable to rates found in the literature review. Suggested methods for improving surgical training and repair outcomes, per the literature review, include attendings reviewing their own outcomes, determining key consistent streamlined surgical steps to teach, concentrated experience of caseloads for residents, and strict guided supervision through the entire procedure. Conclusion: Our results with streamlined and consistent surgical steps and 50% resident involvement demonstrate that it is feasible to incorporate residents into this highly-technical procedure, which helps to build the foundation of microsurgical skills for urology residents without compromising the outcomes or duration of surgery in this special population.

Keywords

• Genital abnormalities
• Hypospadias
• Surgical education
• Reconstruction
• Resident training