Lorenzo AJ, Pippi Salle JL, Zlateska B, Koyle MA, Bagli DJ, Braga LH, J Urol. 2014 May

DOI: 10.1016/j.juro.2013.10.036

Abstract   

Purpose: Hypospadias repair is a commonly performed procedure. Little is known about decisional regret in parents who agree to proceed with this surgical reconstruction. We present data on this previously underexplored issue.

Materials and Methods: We performed followup analysis of 100 couples prospectively evaluated after counseling for surgical correction of distal hypospadias in their son with assessment of complications and decisional regret 1 year after surgery. Findings were contrasted with baseline demographics, hypospadias knowledge and decisional conflict at the time of counseling.

Results: Decisional regret was found in 116 parents, including mild regret in 41.4% and moderate to severe regret in 8.6%. There was no statistically significant difference in paired regret analysis between mothers and fathers. Complications were strongly associated with decisional regret (p <0.001). On regression analysis postoperative complications (OR 14.7, 95% CI 1.6-131.6), parental desire to avoid circumcision (OR 7.4, 95% CI 1.1-49.4) and initial decisional conflict level (OR 1.06, 95% CI 1.02-1.09) were statistically significant predictors of moderate to strong decisional regret. These findings remained robust after imputation strategies to address missing data. The impact of decisional conflict and preference for circumcision were significant even after excluding families who experienced complications.

Conclusions: To our knowledge this is the first study demonstrating parental decisional regret after providing consent for surgical correction of distal hypospadias in their son. Based on the described risk factors efforts aimed at minimizing complications and counseling about foreskin preservation techniques may be prudent to ameliorate decisional regret. The novel association between decisional conflict and regret suggests that conflict assessment during counseling may help screen families at risk for postoperative regret.

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Summary   

Lorenzo et al. studied decisional regret (DR) experienced by parents of children who underwent distal hypospadias repair, assessed at a 1-year follow-up appointment. As with circumcision, the investigators characterized distal hypospadias repair as an “elective nontherapeutic” procedure. In addition to speaking to ongoing clinical management controversies applicable to elective nontherapeutic procedures more generally, this research may hold implications for elective therapeutic procedures.

Having participated in the authors’ previous study {1} in which they completed the Decision Conflict (DC) Scale (n=200), parents (n=116) completed at a 1-year follow-up visit the DR scale. Relationships were found between DR and parental gender (mothers), cosmetic and functional complications (complication rate), preoperative desire for circumcision (none) and DC scores (higher preoperative scores).

This study focused on an outcome of surrogate decision making in genitoplasty that has not yet been explored. Given the association between DC and DR, one implication of this study is to use DC scores to screen families for the probability for future, postoperative, DR. Furthermore, longitudinal studies of the relationship between DR and long-term parental distress should be considered in order to understand the lasting effects of DR on the surrogate decision maker and, potentially, the child’s psychosocial/sexual adaptation.

Finally, although isolated distal hypospadias is not considered to fall under the umbrella of disorders of sex development (DSD) {2}, genitoplasty and vaginoplasty in many young children with DSD share with distal hypospadias the characteristic of being ‘elective’. DR is not necessarily a direct consequence or fully explained by unfulfilled expectations for genital surgery or associated complications. Accordingly, clinicians should proceed cautiously when deciding with the family if it is necessary or desirable to proceed with surgery.

References  

1. Analysis of decisional conflict among parents who consent to hypospadias repair: single institution prospective study of 100 couples. Lorenzo AJ, Braga LH, Zlateska B, Leslie B, Farhat WA, Bägli DJ, Pippi Salle JL. J Urol 2012 Aug; 188(2):571-5
PMID: 22704113 DOI: 10.1016/j.juro.2012.04.022

2. Consensus statement on management of intersex disorders. International Consensus Conference on Intersex. Lee PA, Houk CP, Ahmed SF, Hughes IA, International Consensus Conference on Intersex organized by the Lawson Wilkins Pediatric Endocrine Society and the European Society for Paediatric Endocrinology. Pediatrics 2006 08 01; 118(2):e488-500
PMID: 16882788 DOI: 10.1542/peds.2006-0738

Recommendation Citation  

Sandberg D and Hawver M: F1000Prime Recommendation of [Lorenzo AJ et al., J Urol 2014, 191(5 Suppl):1558-63].