Introduction: HR is technically challenging with a relatively high rate of post-operative complications. Surgical technical psychomotor performance may be influenced by the surgeon's state of mind and positively affected by warm-up activities or negatively affected by fatigue or stress. We evaluated possible risk factors for complications of HR relative to various operative techniques in conjunction with factors associated with the timing of the HR in terms of case order, morning or afternoon, operative delays, and the surgeon’s daily work schedule.
Methods: We retrospectively reviewed the charts of 429 boys undergoing primary one-stage HR with sutured urethroplasty by 1 of 3 surgeons. Factors analyzed and controlled for included surgeon, severity of hypospadias, type of repair, use of caudal block, tourniquet, blanket flap, interrupted vs. continuous sutured urethroplasty, case order, morning or afternoon, number of cases before and after, number of hours of activity scheduled to follow, operative duration, scheduled duration, and time between patient entering operating room and case start. Outcomes were complication rates.
Results: Median age(IQR) at operation was 0.79 (0.57) years and median follow-up was 253 (666) days. The fistula rates for distal, mid-shaft, and proximal hypospadias for the group overall was 9.8, 10.3 and 12.5% (p =0.85). Surgeon 1 had a significantly lower complication rate when using an interrupted sutured urethroplasty compared to a running suture (2.2% vs 16.4%; p=0.02). Surgeon 1 had a significantly lower rate of fistula when one operation was performed prior to the HR (0%) compared to either no operation or 2 operations prior to the HR (17.6% and 30%, respectively; p=0.038). A significant increase in the rate of complications was noted with morning versus afternoon cases for the group overall (22.6 vs 10.6%, respectively; p=0.041). This time of day impact on complication rates was significant for surgeon 3, with an afternoon complication rate of 11.9% compared to 31.1% in the morning (p=0.017).
Conclusions: Novel potential HR complication risk factors were identified in our study and included a decreased risk of complications when the HR was done as the second case of the day and when it was done in the afternoon rather than the morning. Our analysis also demonstrated variability in the level of risk of different factors between surgeons, reinforcing the utility of surgeons monitoring their own individual results in response to changes in their technique.
Source of Funding: Tyrone D. Artz Chair in Urology