Trends in Surgical Management of Hypospadias in Germany: A Nationwide Analysis on legislative and guideline changes

Background Recent years have seen significant changes in the management approach for hypospadias in Germany, influenced by legislative modifications (German Civil Code §1631e), as proximal hypospadias are listed as DSD 46 X, Y, resulting in a family court decision prior to surgery. According to the revised clinical guidelines (S2k guideline, first published 2016, updated 2021), surgical treatment is now mainly indicated for proximal and middle hypospadias. Objective To analyze trends in hypospadias diagnoses and surgical treatments in Germany from 2006 to 2024, focusing on potential impacts of legislative changes and guideline revisions on surgical practice patterns. Methods Analysis of German hospital quality reports (2006-2024), extracting data on hypospadias diagnoses (ICD-10: Q54.0-Q54.9) and surgical procedures (OPS: 5-645). Procedures were categorized by anatomical location and hospital volume. Statistical analyses comprised time-trend assessments and joinpoint regression to detect significant changes in trends. Results Despite stable diagnosis rates (3,225-3,850 cases/year), surgical interventions increased from 3,828 (2006) to 5,564 (2018), followed by a temporary decline during 2019-2021 and recovery to 5,725 (2024). Significant changes in trends were observed in 2009–2010 for distal hypospadias corrections and from 2015 onwards for proximal repairs. A third significant inflection point was identified at 2015 for distal procedures (p=0.016). No significant trend change was associated with the 2021 legislative implementation. The greatest rise in surgical cases was observed in middle-volume hospitals, accompanied by a marked regional clustering of procedures. Conclusion Clinical guideline revisions have a stronger influence on hypospadias surgical practices compared to legislative changes. The temporary decline in procedures during 2019-2021 likely reflects pandemic-related disruptions rather than guideline implementation alone, as surgical volumes have since exceeded pre-pandemic levels. The 2021 legislative change shows no discernible impact on proximal hypospadias correction, even with 43 months of follow-up data suggesting effective preparation and implementation by healthcare providers and governmental bodies.