Distribution of a photographic atlas did not reduce postoperative care utilization after pediatric circumcision or the indispensability of the pediatric urology clinic nurse. Issue 3 (May 2019) - Danzig, Matthew R.
Summary: Background: Surgery in children is increasingly ambulatory, and caregiver responsibilities for postoperative care can produce anxiety. Prior studies have suggested the distribution of a photographic atlas can mitigate caregiver anxiety and reduce clinic phone calls and in-person presentations after pediatric penile surgery. Objective: A pilot study of the ability of a photographic atlas, distributed to caregivers, was aimed to be conducted to reduce postoperative resource utilization. Study design: Patients undergoing circumcision or revision circumcision were randomized to standard postoperative instructions vs. standard instructions with a photographic atlas representing appropriate penile appearance at successive time points. Electronic records were reviewed for phone calls or in-person presentations to the clinic or emergency department (ED) within 1 month of surgery. Results: Fourteen patients (44%) received the atlas, and 18 (56%) did not. Patients who received the atlas did not differ significantly from patients who did not receive it in their rate of clinic phone calls (36% vs 39%, p = 0.85), calls per patient (0.5 vs. 0.7, p = 0.78), ED visits (7% vs. 11%, p = 0.70), calls and visits combined (44% vs. 43%, p = 0.93), or the proportion of calls and emergency room presentations related to concerns about the penile appearance (22% vs. 36%, p = 0.66). Overall, 19 postoperative phone calls were received from 12 patients, and 4 visits to the ED were made by 3 patients. Reasons for calls to the clinic were diverse, and 9 distinct categories of concern were identified apart from wound appearance. Discussion: The impressive diversity of caregiver concerns prompting postoperative communication may partly underlie the failure of the atlas to reduce resource utilization in this study. Most postoperative calls or visits were unrelated to concern about the penile appearance, which limits the degree to which this or any visual guide to wound healing can reduce the need for postoperative attention. Conclusion: Receipt of the atlas did not significantly reduce postoperative contacts or affect the proportion of contacts represented by concerns about penile appearance. Resources must remain directed toward individualized attention to caregiver concerns, delivered by experienced urologic support staffs, who remain the mainstay of postoperative support.