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ORIGINAL RESEARCH
Comparison of Outcome and Success Rate of
Onlay Island Flap and Dorsal Inlay Graft in
Hypospadias Reconstruction: A Prospective Study
This article was published in the following Dove Press journal:
Research and Reports in Urology
Johannes Aritonang
Arry Rodjani
Irfan Wahyudi
Gerhard Reinaldi Situmorang
Department of Urology, Cipto
Mangunkusumo General Referral
Hospital, Faculty of Medicine, Universitas
Indonesia, Jakarta, Indonesia
Background: Chordee correction, urethroplasty, and tissue reconstruction are performed to
correct and retain standard functionality of the penis in hypospadias. Conventional recon-
struction techniques, such as onlay island ap and the dorsal inlay graft, can be performed
based on the classication of hypospadias. However, the outcomes and complication rates
have not been widely studied. Thus, we aimed to provide preliminary evidence regarding the
efcacy and safety of both approaches in hypospadias reconstruction.
Patients and Methods: A prospective study with two time evaluations of 14 and 180 days
post-operatively was performed at the Urology outpatient clinic from October 2014 to
September 2019. A proportion comparison of success rate, time to the complication, opera-
tion time, catheterization duration, uroowmetry parameter post-surgery, and mean scores
comparison of PPPS were measured as the intended outcomes.
Results: In a total of 59 pediatric hypospadias, patients who had undergone reconstruction
are included in this study. Higher subjects’ age and severe chordee severity were more
common in the dorsal inlay graft group (age=7.50 [1–26] months; severe chordee 45.8%)
compared to the onlay island ap group (age=4.0 [1–67] months; severe chordee 31.4%),
both groups showed similar satisfaction regarding meatal shape and position (P=0.618),
glands shape (P=0.324), penile skin shape (P=0.489), and general cosmetic appearance
(P=0.526). Complication occurrence and time to complication duration of both groups
were also not statistically signicant (P=0.464 and P=0.413). There are no signicant
differences in Q
max
, Q
mean
, voided volume, and PVR of both groups (P=0.125, 0.136,
0.076, 0.260, respectively). Signicant differences in operation times and catheterization
duration are found in this study (P<0001).
Conclusion: Outcome evaluation regarding functional, complication and patient satisfaction
comparing onlay ap and dorsal inlay graft for hypospadias patients is scarce. This study found
that both procedures can be considered safe with comparable incidence of complications.
Keywords: chordee correction, urethroplasty, uroowmetry
Introduction
Hypospadias is a congenital external genital disorder most commonly affecting
boys, with an incidence which varies between 1:200 and 1:300. Based on the
classication of pediatric urology guidelines by the European Association of
Urology (EAU) in 2020, hypospadias can be classied as: distal or anterior;
intermediate or middle; and proximal or posterior.
1
In most cases, hypospadias in
children are associated with three anomalies on the penis, namely the ventral
meatus, chordee, and dorsal preputial sheath with a ventral preputium decit.
2
Correspondence: Gerhard Reinaldi
Situmorang
Department of Urology, Cipto
Mangunkusumo General Referral
Hospital, Faculty of Medicine, Universitas
Indonesia, Jakarta, Indonesia
Tel +62 813 1030 3083
Email gr.urorscm@gmail.com
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http://doi.org/10.2147/RRU.S266886
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The surgical procedure has three characteristics, namely
chordee correction, urethroplasty, and tissue reconstruction
that forms part of the ventral radius of the penis (glans,
corpus spongiosum, and skin that aims to improve the
cosmetic appearance of the penis).
3
Several hypospadias
reconstruction techniques can be performed based on the
classication of the hypospadias. The two most commonly
used techniques are the onlay island ap and the dorsal
inlay graft.
The onlay island ap technique developed from the
transverse preputial island ap (TPIF) technique, which
was rst reported by Ducket et al
4
in 1980. Two previous
concepts by Elder et al and Koyanagi et al were adapted
by Mollard et al
5
to developed this Onlay island ap
technique, which is initially used for distal hypospadias
and preservation of the urethral plate. This technique has
been successfully proven in reconstructing hypospadias
with chordees. This method is carried out by apping the
fascia dartos, suturing, and nally covered with the skin of
the penis on the outside. Meanwhile, the dorsal inlay graft
technique aims to maintain the urethral plate and expand
the healthy surface area of the epithelium.
6
In addition,
this technique does not leave a new urethra (neourethra)
caused by a long duration of re-epithelialization. Further,
extension from the incision to the neomeatus at the tip of
the glans can also be carried out in this technique.
4
This
maneuver is very helpful in hypospadias with at glans,
and can be performed in hypospadias either with or with-
out chordee, by reducing the risk of stenosis.
7
Regarding
the advantages and disadvantages between both techni-
ques, the researchers are determined to compare the out-
come and success rate of both procedures.
Patients and Methods
A prospective study of 59 patients with two times evalua-
tion (14 and 180 days post-operatively) was performed at
the Urology outpatient clinic in Cipto Mangunkusumo
General Referral Hospital, Jakarta from October 2014 to
September 2019. Samples are recruited in a total sampling
manner and allocated into two different technique groups
based on indication and operator decision: onlay island
ap and dorsal inlay graft. Surgical indications for the
island onlay and the dorsal inlay are in the cases of
proximal or distal hypospadias, narrow urethral plate,
and moderate–severe chordee. However, in several
patients with a wide urethral plate, the dorsal inlay ap
was used due to brotic tissue and previous surgery his-
tory. As a result, the old urethral plate was not used,
excised, and a new urethral plate was made using an
inlay graft. Only pediatric hypospadias patients aged <18
years who underwent reconstruction for the rst time with
none to mild, moderate, or severe chordee, ventral curva-
ture ≤30º, and with narrow or wide urethral plate were
included in this study. The penile curvature and urethral
plate was assessed pre- and intra-operatively. The urethral
plate was pre-operatively evaluated with physical and
supporting inspection, while pre-operative assessment of
degree was used for penile curvature goniometer. After
that, both the penile curvature and urethral plate were
conrmed intraoperatively. Surgeries were performed by
experienced pediatric urology consultants who regularly
performed both techniques.
Patients’ characteristics observed in this study include
age, type of hypospadias, and concomitant abnormalities
(chordee, penoscrotal transposition, bid scrotum, undes-
cended testis, urethral stricture). Outcomes measured in
this study include functional outcome of maximum ow
(mL/s) measured during uroowmetry (180 days post-
operatively), proportion comparison of success rate, and
mean scores comparison of patient satisfaction index
between both groups. Success rate was measured by the
absence of post-operative complications during evaluation,
while the satisfaction index was measured using the pedia-
tric penile perception screening method (PPPS).
8,9
Patient
identity and pediatric perception screening method were
lled in by the parents. Data regarding uroowmetry
result, post-operative complication evaluation, and recon-
struction technique were obtained by the researchers.
Surgical Technique
In the onlay island ap technique, the patient was in
a supine position with general and caudal anesthesia.
After that, the chordae, curvature, urethral plate, and dor-
sal hood were examined for further steps. The transversal
ap was taken from the preputial skin with one side con-
tinuously sutured into the edge of the urethral plate, while
the other side was interruptedly sutured, both using poly-
dioxanone (PDS). A 6-Fr silastic stent was used for guid-
ing and applied on neourethra to be rolled into a tube
(tubularization). The second layer was made using subcu-
taneous tissues from the preputial aps. Furthermore, gla-
nuloplasty was implemented before the tip of the distal
ap was sutured into the penile glans. The outer skin was
interruptedly sutured with PDS. Further, the bleeding and
scar were controlled and covered with topical antibiotics
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and sterile gauze. In addition, the stent was removed after
7 days.
Similar to the previous technique, the dorsal inlay graft
technique was performed after reexamining the patient in
supine position under general and caudal anesthesia.
Before conducting the surgery, informed consent was
also carried out to determine which technique would be
performed. If severe chordee, narrow urethral plate, and
proximal type of hypospadias were explored during phy-
sical examination, this technique became preferable com-
pared to another one. In addition, history of previous
hypospadias repair was also considered to apply this tech-
nique. This technique will take the graft, which was pre-
viously measured and harvested from the inner prepuce.
Then, the graft was defatted and sutured onto the incised
urethral plate. A 6-Fr silastic stent was also applied for
tubularization in one stage urethroplasty. A vascularized
tunica vaginalis was used to be the second layer. Further,
the raw surface was covered by interrupted suture using
PDS, and the stent was removed after 14 days.
Statistical Analysis
Descriptive analysis was performed using SPSS version
23.0. Patient characteristics were analyzed using chi-
square test. Comparison of functional outcomes (maxi-
mum ow observed during uroowmetry), success and
complications rates and satisfaction indices between
hypospadias reconstruction techniques (Onlay Island
Flap/Dorsal Inlay Graft) were calculated using the Chi-
square or Mann–Whitney test. Independent t-test was per-
formed to calculate the duration of catheterization and
operation time.
Ethical Permission
This study was performed under ethical review and
approval from The Ethics Committee of Faculty
Medicine University Indonesia and Ciptomangunkusumo
Hospital corresponding to ethical approval number 58/
UN2.F1/ETIK/I/2018.
Informed Consent
All study subjects who participated in this study were
properly consented and documented with a standard
informed consent form based on ethical guidelines from
The Ethics Committee of Faculty of Medicine University
Indonesia and Ciptomangunkusumo Hospital. Parental or
legal consent was obtained from all patients under 18
years old. This study also complied with the Declaration
of Helsinki.
Results
A total of 59 pediatric hypospadias patients who had
undergone reconstruction at Cipto Mangunkusumo
General Referral Hospital, Jakarta are included in this
study. Of the 59 subjects included, we gathered 35 subjects
as the onlay island ap arm and the remaining 24 as the
dorsal inlay graft arm (59.3% and 40.7%, respectively).
The pre-operative, post-operative, and 1 month post-
operative clinical appearance of island onlay ap patients
are described in Figure 1. Normality test revealed non-
parametric distribution for age, for which median was used
to describe both groups. Chordee severity was divided into
three categories: none-to-mild, moderate, and severe. Most
of the cases were classied into the moderate chordae
(50.8%), followed by severe and none-to-mild (37.3%
and 11.9%). Hypospadias type was also documented
according to the EAU classication of anterior, middle,
and posterior/proximal of the penis. On all the study sub-
jects, 17 of 59 subjects (28.8%) were categorized with
anterior hypospadias, while 14 (23.7%) and 28 (47.5%)
were categorized with middle and posterior hypospadias,
respectively. A wide urethral plate was observed in 31
(52.5%) of 59 subjects, while the remaining were consid-
ered narrow. Detailed proportions in both of the groups for
chordae severity, type of hypospadias, and urethral plate
size are described in Table 1.
During follow-up evaluation, a standardized PPPS
questionnaire was utilized which documented patients’
satisfaction on four aspects of outcome including position
and meatal position, glands shape, penile skin shape, and
general cosmetic appearance. There is no signicant dif-
ference between both only island and dorsal inlay ap in
all PPPS questionnaire parameter (P=0.125, 0.136, 0.076,
and 0.260, respectively). On both arms, meatal shape and
position, gland shape, and penile skin shape turns out to be
satisfactory for most subjects. While most of the subjects
from both techniques are dissatised about the general
cosmetic appearance post-intervention. In Table 2, the
details spread out of PPPS in both of the groups are
explained. Furthermore, the median observed times to
complication on onlay island ap and dorsal inlay groups
were 19 and 14 months. There is no statistical signicance
between both groups’ complication (P=0.413).
Five (20.8%) complication occurrences were observed
in the dorsal inlay groups which were due to
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urethrocutaneous stula (two; 8.3%), urethral stricture
(one; 4.2%), and failed hypospadias due to brotic tissue
(two; 8.3%). Urethrocutaneous stula were repaired by
redo urethroplasty or excision and primary closure.
Stricture on dorsal inlay groups were treated using
urethroplasty with full thickness skin graft. Redo urethro-
plasty with excision of brotic tissue were done on both
failed hypospadias repair. In the onlay island ap group,
four occurrences of complication (11.4%) were observed,
which consisted of two urethrocunateous stula cases
(5.7%) and two failed hypospadias (5.7%), with one case
suspected with balanitis xerotica obliterans (BXO). For
urethrocutaneous stula on onlay island ap group, redo
urethroplasty and stulectomy were conducted while
penile reconstruction and redo urethroplasty were per-
formed to treat failed hypospadias cases in this group.
Uroowmetry examinations were performed after both
hypospadias interventional surgery. There is no statistical
difference in the Q
max
, Q
mean
, voided volume, and post-
void residual (PVR) between the onlay island ap and
dorsal inlay graft (Table 3). The time needed to perform
both techniques was recorded. Onlay island ap provided
a shorter operation time and catheterization compared to
dorsal inlay graft (169.2±28.6, 5.3±0.6 vs 254.4±40.1, 7.1
±0.3; P<0.001).
Discussion
This study has been able to gather a total of 59 hypospa-
dias cases in the course of 5 years during the study
intended duration. Since hypospadias occurrence is
approximated to be 1:200 to 1:300 among newborn
males, the total subjects in this study can be considered
smaller than expected, since the number of newborns in
Table 1 Subjects Characteristics
Variables Onlay
Island
Flap
(n=35;
59.3%)
Dorsal
Inlay
Graft
(n=24;
40.7%)
Total
(n=59;
100%)
P-value
Age 4.0 (1–67) 7.50 (1–26) 4.0
(1.0–67.0)
Chordee Severity
None-to-
Mild
3 (8.6%) 4 (16.7) 7 (11.9) 0.002
Moderate 21 (60%) 9 (37.5) 30 (50.8)
Severe 11 (31.4) 11 (45.8) 22 (37.3)
Urethral Plate Size
Narrow 17 (48.6) 11 (45.8) 28 (47.5) 0.839
Wide 18 (51.4) 13 (54.2) 31 (52.5)
Type of Hypospadias
Anterior 11 (31.4) 6 (25) 17 (28.8) 0.694
Middle 9 (25.7) 5 (20.8) 14 (23.7)
Posterior 15 (42.9) 13 (53.2) 28 (47.5)
Notes: P<0.002. There is a signicantly statistical difference between the two groups.
Figure 1 Island onlay ap technique. (A) Patient pre-operative proximal hypospadias clinical appearance. (B) Surgical site marking on the patient penis. (C) Post-operative
clinical appearance of patient. (D) One-month post-operative follow-up of the patient.
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Jakarta each year is estimated to be around 200,000. The
incidence might be lower due to several factors, such as
the implementation of universal health coverage and the
mandatory referral system in Indonesia since 2014.
10
Starting from a similar period which coincided with this
study time frame, we observed a decreased number of
hypospadias cases treated in several referral centers in
Indonesia. However, other factors such as patient care
seeking behavior and screening programs might play
a signicant role in the incidence number of hypospadias.
Springer
8
described their nding on the prevalence of
hypospadias and found the number varies greatly, espe-
cially in Asian countries, due to the different healthcare
systems. Since Indonesia has implemented a screening
program for newborns, infants, and school-age, the major-
ity of hypospadias cases should be recognized from an
early age. However, Pratiwi and Basuk
11
previously men-
tioned in their study that health seeking behavior in
Indonesia can be considered low, especially in the rural
area where midwives play a huge role on educating the
family to seek medical treatment.
Of the 59 subjects in this study, we gathered 35 sub-
jects on onlay island ap group and 24 subjects on dorsal
inlay graft group. There is a median difference in which
the dorsal inlay group had a higher period of observed
complication occurrence than the onlay group (7.5 [1–26]
months vs 4 [1–67] months) but both numbers can be
considered early since another study with a similar time
frame and population conducted by Nerli et al
12
observed
a higher number of age mean 48.83±8.29 (range=36–67)
months when undergoing reconstructive surgery.
Comparing the proportion based on chordee severity, we
observed a similar tendency of patients treated on both
groups to be categorized on moderate-to-severe (propor-
tion of moderate and severe chordee of 60% and 31.4% on
onlay island graft group and 37.5% and 45.8% on dorsal
Table 3 Uroowmetry Outcome, Operation Time, and
Duration of Catheterization Comparison Between Onlay Island
Flap and Dorsal Inlay Graft
Outcome Variable Onlay
Island
Flap
Dorsal
Inlay
Graft
P-value
Uroowmetry Result
Q
max
6.2
(4.2–22.4)
10.1
(4.8–22.8)
0.125
Q
mean
3.9
(2.4–12.1)
5.1 (3–13) 0.136
Voided volume 48
(28–247)
64
(33–337)
0.076
PVR 2 (0–26.9) 2.7 (0–25.7) 0.260
Operation Time
Mean of operation time
(minutes)
169.2±28.6 254.4±40.1 <0.001
Duration of Catheterization
Mean of duration of
catheterization (minutes)
5.3±0.6 7.1±0.3 <0.001
Notes: P<0.001. There is signicant statistical difference between two groups.
Table 2 Outcome Comparison Between Onlay Island Flap and
Dorsal Inlay Graft
Outcome Variables Onlay Island
Flap
Dorsal Inlay
Graft
P-value
Patient Satisfaction
Meatal Shape and
Position
Very Dissatised 0 (0) 0 (0) 0.618
Dissatised 4 (11.4) 4 (16.7)
Satised 22 (62.9) 15 (62.5)
Very Satised 9 (25.7) 5 (20.8)
Glands Shape
Very Dissatised 0 (0) 1 (4.2) 0.324
Dissatised 2 (5.7) 3 (12.5)
Satised 23 (65.7) 14 (58.3)
Very Satised 10 (28.6) 7 (29.2)
Penile Skin Shape
Very Dissatised 0 (0) 0 (0) 0.489
Dissatised 4 (11.4) 2 (8.3) 16
Satised 23 (65.7) (66.7)
Very Satised 8 (22.9) 6 (25)
General Cosmetic
Appearance
Very Dissatised 0 (0) 0 (0) 0.526
Dissatised 5 (14.3) 3 (12.5)
Satised 25 (71.5) 15 (62.5)
Very Satised 5 (14.3) 6 (25)
Complication Occurrence
Yes 4 (11.4) 5 (20.8) 0.464
No 31 (88.6) 19 (79.2)
Time to Complication
Median Months
(Min-Max)
19 (10–28) 14 (6–21) 0.413
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inlay group, respectively). This aligned well with hypos-
padias types observed in this study, which mainly consist
of posterior/proximal type on both groups (42.9% and
53.2% on onlay island ap and dorsal inlay group, respec-
tively) which is similar to several studies.
13,14
Onlay island
ap technique is commonly used in both minimal or mod-
erate chordee and severe chordees in our center. After
performing penile degloving, orthoplasty and urethroplasty
by transversal apping in preputial skin were also per-
formed. Urethral plate observed on both intervention
groups returned almost to a 1:1 ratio between narrow and
wide urethral plate and both groups did not show
a signicant difference during statistical analysis.
We presented three outcomes of complication rate,
uroowmetry result, and patient satisfactory score using
the pediatric penile perception screening method.
Complications following hypospadias repair are common
and include stricture, stula, and diverticulum formation.
During the past decades, the most common technique of
proximal hypospadias repair involved the use of
a vascularized transverse preputial island ap as
a tubularized neourethra or as a ventral onlay over an
intact urethral plate.
15
The results of these procedures
were satisfactory and improved over time. From our
study, we documented ve complication occurrences
in the dorsal inlay graft group and four occurrences
in the onlay island ap group during the study time
frame on follow-up of 180 days after the surgery. One
patient in this occurrence only comprises of 11.4% group
subjects undergone onlay island ap and 20.8% of subjects
undergone dorsal inlay graft. These incidences can be
considered within the normal limit, since observations by
Sheng et al
16
showed that complications from hypospadias
repair may comprise up to 32.5% of all treated patients.
Time from hypospadias repair to complication occurrence
observed in this study also aligns well with the
observations of Sheng et al,
16
which mostly occurred dur-
ing 6–24 months of follow-up. However, this number can
vary wildly from different operators and centers. Findings
by Asanuma et al
17
seemed to conrm this idea which
observed stula occurrence in oneof 28 subjects at a mean
of 22 months follow-up. Further statistical analysis on
complication occurrence and time to complication for
both intervention groups yielded an insignicant differ-
ence. These ndings may indicate that one approach does
not have higher correlation with complication occurrences
nor time to occurrences compared with another interven-
tion group.
We compared both groups’ satisfaction and documen-
ted the result as shown in Table 2. From Mann–Whitney
analysis, most patient reported satisfactory results in both
groups. Proportion comparison between both groups for
meatal shape and position aspect show an insignicant
statistical difference (P-value=0.618) between both
groups, implying that both techniques produce a similar
satisfactory position and meatal position outcome for the
patients. Between both intervention arms, the majority of
subjects found satisfactory or very satisfactory gland shape
outcome after undergoing the procedure. Subjects replying
as satised and very satised on the PPPS questionnaire
comprised 94.3% and 87.5% in the onlay island ap and
dorsal inlay graft group, respectively, with a P-value of
0.324. Similar results were observed for penile skin shape
and general cosmetic appearance during evaluation with
a P-value of 0.489 and 0.526, respectively. This is aligned
with a study conducted by Weber et al,
18
which compared
the PPPS score from a normal population and hypospadias
patients from age 7–17 years. The study found that, com-
pared to controls, there are no differences of penile shape
perception between both groups. Another similar study
conducted by Schönbucher et al
19
also showed similar
results where control groups and hypospadias patients
showed no difference and both groups perceived a high
level of satisfaction. A long-term follow-up by Fraumann
et al
20
found that even after long-term follow-up, 85% of
18–30 years old hypospadias boys also showed very posi-
tive satisfaction, although 35% of them reported residual
curvature. Another study by Jones et al reported that
almost 31.4% of hypospadias patient perceived their
penis looked abnormal, but, despite this condition, 81%
were satised with the overall cosmetic status and it did
not affect their body image, which conrms our ndings.
Although we did not compare with a normal population as
a control, our ndings show a high level of satisfaction
between both intervention groups and, thus, aligned with
the goal of the reconstruction conducted.
This study also compares the uroowmetry parameter
of Q
max
, Qv
olume
, voided volume, and PVR between two
interventional groups. There are no signicant differences
in all of those parameters between two groups (P=0.125,
0.136, 0.076, 0.260, respectively). This result suggested
that both the onlay island ap and dorsal inlay graft
produced good and adequate uroowmetry parameters.
Moreover, operation time also took account as
a parameter to see the differences between two techniques.
This study operative duration of dorsal inlay graft is
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espoused to Asanuma et al's
17
result of 200 minutes
(range=154–249 minutes). The onlay island ap required
a shorter period due to its single stage procedure (169.2
±28.6 minutes). The duration of catheterization is also
important to be observed due to its connection to urinary
tract and systemic infections. Shorter catheterization dura-
tion is observed in onlay island ap groups (5.3±0.6 vs 7.1
±0.3, P<0.001). Therefore, time efciency of onlay island
ap techniques became a reason for the urologist to prior-
itize or choose this technique compared to the dorsal inlay
graft for hypospadias management.
Our analysis is subject to some limitations. First, this is
a prospective study. We did not perform any experimental
intervention in the patient. The classication of patient inter-
vention is then determined solely based on the indication and
discretion by the operator. Second, in the patient group deter-
mination there is no randomization process which increases
the likelihood of bias. Moreover, there is a statistically sig-
nicant gap in the patient characteristics between two groups
in the chordee severity, which means the baseline character-
istics are not sufciently standardized. Some cases have been
monitored for 180 days in our study. There is, however, a small
share of patients that were followed only by 3 months. Among
such categories, there is a chance that the patient is not present
with any complications such as strictures or stula due to lack
of a follow-up period.
Conclusion
Outcome evaluations regarding functional, complication,
and patient satisfaction comparing onlay ap and dorsal
inlay graft for hypospadias patients are scarce. This study
found that both procedures can be considered safe with
comparable incidence of complications. Because hypospa-
dias surgery is a constantly evolving art, long-term studies
(into adulthood) will continue to be important and will
need to be repeated for each new procedure developed if
surgeons are to continue to provide an honest and mean-
ingful account of their results.
Funding
Funding was received from our institution Faculty
Medicine University Indonesia, Ciptomangunkusumo
Hospital, Jakarta, as an operational research grant. We
can conrm that there was no external organization or
company sponsorship in this study.
Disclosure
The authors declare no conicts of interest for this work.
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