The Sydney Children’s Hospital Network DSD multidisciplinary team (MDT) meetings are a forum to support consistent decision making for children and adolescents with DSD and complex hypospadias (CH) (defined as peno-scrotal hypospadias or any hypospadias with undescended testis, microphallus or bifid scrotum). To minimise inconsistencies in referral patterns and enable a time efficient and streamlined review of patients with CH, a flow chart for diagnostic work up and checklist based peer review process to document the decision making process prior to any surgical intervention was introduced in 2021.
All patients have endocrine investigations, a chromosome microarray and are offered a DSD gene panel as per the flowchart. The checklist incorporates clinical details and 11 items which include documentation of clinical discussions by treating clinicians on aspects of investigations, awareness of surgical sequelae and long term outcomes. The checklist is reviewed by the conveners of the DSD MDT and if found acceptable, filed in the patient’s medical records. If not suitable for the checklist, the case is brought to full discussion at the MDT.
Since 2018, 36 cases of CH were reviewed by the MDT, 16 prior to introduction of the checklist by full discussion and 20 since introduction (all checklist). All had minipuberty and/or HCG stimulation hormone testing. Despite variable uptake of genetic testing, variations were found in 11, 5 were pathogenic. 17 have proceeded on to correction of hypospadias surgery and 18 are currently on surgical waiting lists, with one family deciding to defer surgical intervention. The average turnaround time for checklist review was 1 week.
The introduction of a flowchart and a peer reviewed checklist system has streamlined the MDT process for complex hypospadias, whilst maintaining consistent evidence based management, and enabled greater time for patients requiring more complex and ethically challenging discussions by the DSD MDT.