Challenges in the management of proximal hypospadias for early-career pediatric urologists.

BACKGROUND: Proximal hypospadias repair is technically complex, with numerous surgical techniques and variable outcomes. Fellowship programs aim to prepare trainees for independent practice, but case exposure is often limited and inconsistent. The challenges faced by early-career pediatric urologists and how fellowship training and early career support can be improved remain unclear. OBJECTIVE: To examine the experiences and challenges of early-career pediatric urologists in the management of patients with proximal hypospadias. STUDY DESIGN: An anonymous, web-based survey was sent to fellowship-trained pediatric urologists within 1-5 years of completing a 2-year ACGME (Accreditation Council for Graduate Medical Education)-accredited fellowship to assess fellowship experiences, perceived preparedness for practice, and early-career challenges in managing proximal hypospadias. Respondent demographics were obtained. Survey items were analyzed descriptively with proportions (n/N (%)). Not all survey items were completed by each participant. Subgroup analyses of respondents with 1-2 years ("less experienced") versus 3-5 years ("more experienced") of practice were performed using chi-square and Fisher's exact tests. RESULTS: Of 92 individuals contacted, 40 (43.5%) responded. Most were male (21/39; 53.8%), aged 30-39 years (33/39; 84.6), and practiced in academic settings (34/39; 87.2%). Although most respondents felt very well prepared for preoperative, operative, and postoperative care after fellowship, early-career challenges were identified, including difficulty with intraoperative decision-making (25/38; 65.8%), low case volume (21/38; 55.3%) and postoperative complication management (16/38; 42.1%). Since fellowship, 74.4% (29/39) performed fewer than 10 proximal hypospadias cases annually. While informal mentorship was common (31/39; 79.5%), formal mentorship was rare (1/39; 2.6%). Respondents frequently used discussions with senior colleagues (34/39; 87.2%), fellowship notes (29/39; 74.4%) and surgical videos (26/39; 66.7%) to prepare for complex cases. Respondents felt the most helpful supports were observing senior colleagues (29/38; 76.3%), hands-on courses (24/38; 63.2%) and direct mentorship after fellowship (23/38; 60.5%). Less experienced respondents reported lower case volumes (p = 0.02) and most frequently identified infrequent case exposure as primary early-career challenge (p = 0.004). Reported modifications to surgical approach since fellowship differed significantly between groups (p < 0.001). DISCUSSION: While most respondents felt well prepared to undertake proximal hypospadias repair upon fellowship completion, this preparedness did not always translate into confidence during early career independent practice. Low case volumes and the desire for additional mentorship emerged as key components to improve confidence, highlighting the potential value of implementing alternative mentorship programs and targeted training models for proximal hypospadias. CONCLUSION: Primary early career challenges included intraoperative decision-making and limited case exposure. Structured mentorship programs and targeted educational strategies may better support early-career pediatric urologists managing complex, low-frequency proximal hypospadias cases.