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Introduction: Severity of penile curvature (PC) is commonly used to select the optimal surgical intervention for hypospadias, either alone or in conjunction with other phenotypic characteristics. Despite this, current literature on the accuracy and precision of different PC measurement techniques in hypospadias patients remains limited., Purpose: Assess the feasibility and validity of an artificial intelligence (AI)-based model for automatic measurement of PC., Material and Methods: Seven 3D-printed penile models with variable degrees of ventral PC were used to evaluate and compare interobserver agreement in estimation of penile curvatures using various measurement techniques (including visual inspection, goniometer, manual estimation via a mobile application, and an AI-based angle estimation app. In addition, each participant was required to complete a questionnaire about their background and experience., Results: Thirty-five clinical practitioners participated in the study, including pediatric urologists, pediatric surgeons, and urologists. For each PC assessment method, time required, mean absolute error (MAE), and inter-rater agreement were assessed. For goniometer-based measurement, the lowest MAE achieved was derived from a model featuring 86° PC. When using either UVI (unaid visual inspection), mobile apps, or AI-based measurement, MAE was lowest when assessing a model with 88° PC, indicating that high-grade cases can be quantified more reliably. Indeed, MAE was highest when PC angle ranged between 40° and 58° for all the investigated measurement tools. In fact, among these methodologies, AI-based assessment achieved the lowest MAE and highest level of inter-class correlation, with an average measurement time of only 22 s., Conclusion: AI-based PC measurement models are more practical and consistent than the alternative curvature assessment tools already available. The AI method described in this study could help surgeons and hypospadiology researchers to measure PC more accurately., Competing Interests: Conflict of interest All co-authors have nothing to declare., (Copyright © 2023 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Objective: To improve hypospadias classification system, we hereby, show the use of machine learning/image recognition to increase objectivity of hypospadias recognition and classification. Hypospadias anatomical variables such as meatal location, quality of urethral plate, glans size, and ventral curvature have been identified as predictors for postoperative outcomes but there is still significant subjectivity between evaluators., Materials and Methods: A hypospadias image database with 1169 anonymized images (837 distal and 332 proximal) was used. Images were standardized (ventral aspect of the penis including the glans, shaft, and scrotum) and classified into distal or proximal and uploaded for training with TensorFlow. Data from the training were outputted to TensorBoard, to assess for the loss function. The model was then run on a set of 29 "Test" images randomly selected. Same set of images were distributed among expert clinicians in pediatric urology. Inter- and intrarater analyses were performed using Fleiss Kappa statistical analysis using the same 29 images shown to the algorithm., Results: After training with 627 images, detection accuracy was 60%. With1169 images, accuracy increased to 90%. Inter-rater analysis among expert pediatric urologists was k= 0.86 and intrarater 0.74. Image recognition model emulates the almost perfect inter-rater agreement between experts., Conclusion: Our model emulates expert human classification of patients with distal/proximal hypospadias. Future applicability will be on standardizing the use of these technologies and their clinical applicability. The ability of using variables different than only anatomical will feed deep learning algorithms and possibly better assessments and predictions for surgical outcomes., (Copyright © 2020 Elsevier Inc. All rights reserved.)

Background: Estimation of the quality of the urethral plate (UP) seems to be important when assessing postoperative outcomes of hypospadias repair, but its evaluation remains subjective. We developed an objective model aiming to standardize this assessment, proposing a methodology that could be adopted in future studies designed to evaluate outcomes in the treatment of hypospadias., Objectives: To evaluate the inter and intra observer reliability of a method to assess the quality of the urethral plate (UP) in hypospadias (POST - Plate Objective Scoring Tool) based on elements of glans characteristics. The reliability of such scoring methodology was compared to an analog accepted tool: the Glans-Urethral Meatus-Shaft (GMS) score. A secondary goal was to compare some characteristics of the UP in GMS score to POST values; aiming to find the threshold between favorable and unfavorable plates., Methods: Data were prospectively obtained from prepubertal boys who underwent primary hypospadias repair between January 2018 and November 2019. Intrinsic elements of the glanular UP (A: distal midline mucocutaneous junction; B: Glanular knob where the mucosal edges of the UP's edge change direction; C: Glanular/coronal junction) were marked and the AB/BC ratio calculated. The "G" and "M" components of the GMS score were measured electronically three times by four different reviewers with variable pediatric urology experience and blinded to each other values. Favorable UP, according to the GMS score was compared to measurements obtained by POST (AB/BC ratio)., Results: 84 subjects were enrolled. The POST score had an excellent inter-observer agreement for the evaluation of the UP in distal hypospadias (Kappa = 0.832) while the "G" parameter of the GMS correlated poorly among the observers. The Inter-Class Correlation (ICC) analysis to examine the intra-rater agreement value was 0.914 (95% CI 0.87, 0.95.). AB/BC ratio values ranged from 0.6 to 1.6, with a mean of 1.12. The POST cut-off value for "favorable" UP was 1.2 (AUC = 0.62) 95% CI (0.52-0.84) (sensitivity 80% and specificity 60%)., Conclusions: The POST score has higher inter-observer reliability and functions favorably when compared to the GMS. In addition, it demonstrated a high intra-observer reliability among observers of variable experience. Our findings suggest that the POST score adds to evaluation of the UP and could be incorporated as an additional criterion to assess outcomes in distal hypospadias repairs., Competing Interests: Conflicts of interest All co-authors have nothing to declare., (Copyright © 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

The majority of patients with DSD will be found to carry an XY karyotype and be assigned male gender. From a phenotypical standpoint, most will present with proximal hypospadias ± cryptorchidism. In this review article, the authors present the current status of reconstruction of the male genitalia in this setting. The report addresses the following topics: surgical input in the evaluation of the newborn with an undervirilized external genitalia, including gender assignment considerations; controversies surrounding timing and indication for hypospadias surgery in proximal cases as well as use of testosterone; surgical techniques and decision-making process for one- vs. two-stage repairs; complications of hypospadias surgery based on technique used for repair; and long-term follow-up. The high complication rates observed in the treatment of proximal hypospadias attest to its challenging nature. Concentration of experience, tracking carefully identified patient-centered outcomes and long-term follow-up of this patient population are recommended., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Introduction: Observational studies, particularly case series, represent the majority of the current hypospadias research. As a result, this literature lacks standardization of surgical techniques, uniform definitions of hypospadias complications, and consistency of outcome reporting, which may make it difficult to compare results across studies. A modified version of the STROBE statement, containing 20 items, was presented at the International Pediatric Urology Task Force on Hypospadias meeting to assist with clear and transparent reporting of hypospadias studies. The adoption and implementation of this modified tool will allow investigators and health care providers to critically evaluate quality and identify bias within the literature. In addition this instrument will ensure consistency of reporting, improving objective comparisons between studies, unification of results, and development of evidence-based clinical guidelines., Methods: In this article, we have applied the modified STROBE statement to the hypospadias literature, aiming to create a guide on study reporting for pediatric urologists, and ultimately improve the quality of research in our field. We present itemized recommendations for adequate reporting of hypospadias studies and case series, ranging from drafting the abstract to addressing biases and potential sources of confounding. Included with each item is a brief explanation of its importance and potential effect on the study, as well as pertinent examples of hypospadias articles., Results: A modified STROBE summary table containing 20 items is presented in (Supplementary Table 1)., Conclusions: If properly conducted and reported, hypospadias studies have the potential to provide useful information to clinicians and surgeons. However, authors should recognize the inherent limitations of these observational studies, especially in the form of bias, which may introduce invalid data or limit generalizability. Thus, we expect that the use of this guiding tool will not only improve transparency of hypospadias reporting, but also improve its methodological quality, allowing proper comparison and interpretation of data across different institutions., (Copyright © 2016 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Introduction: The optimal treatment of proximal hypospadias remains controversial. Several techniques have been described, but the best approach remains unsettled., Objective: To evaluate and compare the complication rates of proximal hypospadias with and without ventral curvature (VC), according to three different surgical techniques: tubularized incised plate (TIP) uretroplasty, dorsal inlay graft TIP (DIG), and staged preputial repair (SR). It was hypothesized that SR performs better than TIP and DIG for proximal hypospadias., Methods: Single-center, retrospective chart review of all patients with primary proximal hypospadias reconstructed between 2003 and 2013. The DIG was selectively employed in cases with narrow urethral plate (UP) and deficient spongiosum. Extensive urethral plate (UP) mobilization (UPM), dorsal plication (DP) and/or deep transverse incisions of tunica albuginea (DTITA) were selectively performed when attempting to spare transecting the UP. Division of UP and SR was favored in cases with severe VC (>50°), which was often concurrently managed with DTITA if intrinsic curvature was present. For SR, tubularization of the graft was performed 6 months later., Results: A total of 140 patients were included. Tubularized incised plate (TIP), DIG, and SR techniques were performed in 57, 23, and 60 patients, respectively. The TIP and DIG techniques achieved similar success rates, although DIG was performed in cases of narrow and spongiosum-deficient plates. Reoperation rates with TIP and DIG techniques was 52.6% and 52.1% (NS). Urethro-cutaneous fistulas were seen in 31.5% and 13% of TIP and DIG techniques, respectively. Staged repair accomplished better results than both TIP and DIG techniques, despite being performed in the most unfavorable cases (reoperation rate 28%). After technical modifications, the DIG technique achieved similar outcomes of SR., Conclusions: Proximal hypospadias remains challenging, regardless of the technique utilized for its repair. Urethro-cutaneous fistulas were more commonly seen after long TIP repairs. Approximately half of the patients undergoing long TIP and DIG procedures needed re-intervention, although the percentage decreased significantly with late modifications in the DIG group. Recurrence of VC after TIP and DIG techniques seemed to be a significant and under-reported complication. Staged repairs, despite being performed for the most severe cases, resulted in overall better outcomes., (Copyright © 2015 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: Hypospadias repair is a commonly performed procedure. Little is known about decisional regret in parents who agree to proceed with this surgical reconstruction. We present data on this previously underexplored issue., Materials and Methods: We performed followup analysis of 100 couples prospectively evaluated after counseling for surgical correction of distal hypospadias in their son with assessment of complications and decisional regret 1 year after surgery. Findings were contrasted with baseline demographics, hypospadias knowledge and decisional conflict at the time of counseling., Results: Decisional regret was found in 116 parents, including mild regret in 41.4% and moderate to severe regret in 8.6%. There was no statistically significant difference in paired regret analysis between mothers and fathers. Complications were strongly associated with decisional regret (p <0.001). On regression analysis postoperative complications (OR 14.7, 95% CI 1.6-131.6), parental desire to avoid circumcision (OR 7.4, 95% CI 1.1-49.4) and initial decisional conflict level (OR 1.06, 95% CI 1.02-1.09) were statistically significant predictors of moderate to strong decisional regret. These findings remained robust after imputation strategies to address missing data. The impact of decisional conflict and preference for circumcision were significant even after excluding families who experienced complications., Conclusions: To our knowledge this is the first study demonstrating parental decisional regret after providing consent for surgical correction of distal hypospadias in their son. Based on the described risk factors efforts aimed at minimizing complications and counseling about foreskin preservation techniques may be prudent to ameliorate decisional regret. The novel association between decisional conflict and regret suggests that conflict assessment during counseling may help screen families at risk for postoperative regret., (Copyright © 2014 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: To examine the development of recurrent urinary tract infections (UTIs) in boys who have undergone hypospadias repair., Materials and Methods: We retrospectively reviewed the records of all boys who had recurrent UTIs after primary or redo tubularized incised plate (TIP) or transverse island flap (TVIF) repairs, between 1998 and 2009. Data on age, operating details, postoperative complications and imaging studies were collected. We attempted to identify risk factors for recurrent UTIs after hypospadias repair., Results: During the study period, 43/2249 boys (1.91%) were diagnosed with recurrent UTIs after hypospadias repair. The boys' mean (range) age at repair was 14 (6-24) months and the median (range) follow-up was 6.5 (1.5-11) years. Primary TIP and TVIF were performed in 47% (20/43) and 35% (15/43) of the boys, respectively. Redo surgeries were performed in 18% of the boys (8/43). The initial meatal location was proximal in all TVIF and redo repairs, and in one of the TIP repairs. Postoperative voiding cysto-urethrography, ultrasonography and dimercapto-succinic acid (DMSA) scans were performed in 58% (25/43), 90% (39/43) and 19% (8/43) of the boys, respectively. Abnormalities were noted. Of those boys who underwent a TVIF repair, urethral diverticula were seen in 47% (7/15) and urethral fistulae were also seen in 47% (7/15). Conversely, in those who had a TIP repair, an elevated PVR and vesico-ureteric reflux were more common; they were found in 40% (8/20) and 50% (10/20) of patients, respectively., Conclusions: The pathophysiology of recurrent UTI is multifactorial, but postoperative complications seem to vary with type of procedure. Recurrent UTIs after hypospadias surgery should prompt a specific assessment for potentially functionally relevant and correctable anatomical abnormalities., (© 2013 The Authors. BJU International © 2013 BJU International.)

Objective: Abnormal uroflowmetries are common after tubularized incised plate urethroplasties (TIP), perhaps due to low compliance. We hypothesized that (1) abnormal uroflowmetries after TIP might be caused by segmental lower compliance; (2) by adding a graft to the raw area in the incised plate (TIPG), compliance might be improved by preventing secondary intention healing of the dorsal incision., Methods: A standardized penectomy was performed in 27 adult male rabbits: 9 normal non-operated controls (G1), 6 weeks after TIP (G2: n = 9) or TIPG (G3: n = 9). A standardized isolated segment (including the whole urethroplasty in G1 and G2) was progressively distended with air (1, 2 and 3 ml) in the 3 groups. The respective intraluminal pressures were measured with a tensiometer., Results: Pressure measurements were feasible and reproducible for this model. Mean pressures tended to be higher in the experimental groups (G1: 59.7 mmHg vs. G2: 79.6 mmHg vs. G3: 100.1 mmHg for 1 ml injections; G1: 233.1 mmHg vs. G2: 241 mmHg vs. G3: 308.4 mmHg for 2 ml injections and G1: 457.3 mmHg vs. G2: 429 mmHg vs. G3: 520 mmHg for 3 ml injections) without reaching the statistical significance., Conclusion: In this model, the elasticity of the TIP or TIPG neourethras tended to be reduced when compared to controls. The placement of an inlay graft on the dorsal incised area did not increase the compliance. This model allows the measurement of segmental intraluminal urethral pressures generated by controlled air distension and may be a useful tool to evaluate the experimental urethroplasty models.

Purpose: Although obtaining informed consent for distal hypospadias repair is common practice, little is known about the uncertainty or conflict between consenting parents faced with this decision. We systematically evaluated decisional conflict between parents who elected to have their child undergo hypospadias surgery., Materials and Methods: A total of 100 couples who were counseled about treatment options agreed to participate. Using a validated questionnaire, the Decisional Conflict Scale, we prospectively collected data on decisional conflict demographics, preference for circumcision, education level and prior knowledge about hypospadias., Results: All parents elected surgical repair. Evidence of decisional conflict was encountered in 28% of participants (score less than 25 in 72%, 25 to 37.5 in 23.5%, greater than 37.5 in 4.5%). No statistically significant differences among parents were noted for total score (mean ± SD 16.1 ± 12 in mothers and 18.3 ± 12.6 in fathers) or subscales, except the informed subscale (mean ± SD 16.7 ± 14.3 in mothers and 21.1 ± 16.6 in fathers). Parental self-report of prior knowledge about hypospadias and preference for neonatal circumcision correlated with lower Decisional Conflict Scale scores (p = 0.02 and p <0.01, respectively). No statistical association was found between score and parental education level (p = 0.7) or expertise of the counselor (staff vs pediatric urology fellow, p = 0.4)., Conclusions: These data describe the level of decisional conflict in couples agreeing to proceed with hypospadias repair, with no evidence of significant discrepancy between them. The novel description of factors related to decreased decisional conflict might help focus efforts aimed at minimizing difficulties encountered during the decision making process., (Copyright © 2012 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: We analyzed the histological and functional characteristics of the tubularized incised plate vs dorsal inlay graft urethroplasty in an experimental rabbit model., Materials and Methods: A total of 24 New Zealand male rabbits were randomly allocated into 4 groups, including sham operation, urethroplasty, tubularized incised plate urethroplasty and dorsal inlay graft urethroplasty. In the urethroplasty group the anterior urethral wall was half excised and the dorsal aspect was tubularized. In the tubularized incised plate group the same steps were followed but tubularization followed a longitudinal midline incision in the dorsal wall. In the dorsal inlay graft group the defect created by the dorsal incision was covered with an inner preputial graft. The animals were sacrificed at 4 and 8 weeks, respectively. The penis was immediately harvested for standardized passive flowmetry and subsequently fixed for histological staining., Results: The grafts took in all animals. The tubularized incised plate defect was bridged by urothelium while in the dorsal inlay graft group the preputial graft kept its original histological characteristics. There was a significant decrease in average flow in the urethroplasty group (1.6 ml per second) compared to that in the sham operated group (3.4 ml per second) and to the other groups (p <0.05). However, no significant difference in average flow was found for the tubularized incised plate and dorsal inlay graft groups (2.4 and 2.2 ml per second, respectively, p = 0.7)., Conclusions: In this short-term rabbit model dorsal inlay graft urethroplasty was feasible with good graft take and integration. Simple tubularization of a reduced urethral plate led to significantly decreased flow. Incision of the reduced plate with or without grafting improved the average flow. Findings in this experimental model do not support the superiority of dorsal inlay graft urethroplasty over tubularized incised plate urethroplasty in terms of urethral flow dynamics., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Purpose: Although staged buccal mucosa graft urethroplasty is a well accepted technique for salvage urethroplasty, there are few reports on this procedure for redo hypospadias repair in children., Materials and Methods: We reviewed patients who underwent staged buccal mucosa graft urethroplasty for redo hypospadias repair. Age, quality of graft before tubularization, meatal position, presence of balanitis xerotica obliterans and complications were recorded., Results: A total of 30 patients underwent 32 repairs during a 5-year period. Mean age at first stage was 7 years (range 1 to 17) and mean interval between stages was 9.3 months (5 to 13). Mean followup after second stage was 25 months (range 10 to 46). Meatal position before first stage was proximal in 44% of patients, mid shaft in 39% and distal in 16%. Nine patients had biopsy proved balanitis xerotica obliterans. There were no donor site complications. Four patients underwent a redo grafting procedure. Complications after second stage occurred in 11 of 32 repairs (34%), consisting of urethral stenosis in 5, glanular dehiscence in 3 and urethrocutaneous fistula in 3. A third of the patients had some degree of graft fibrosis/induration after the first stage. These patients were prone to more complications at second stage (9 of 11, 82%), compared to patients without these unfavorable findings (4 of 21, 19%; p<0.001). Presence of balanitis xerotica obliterans and meatal position were not significant factors associated with adverse outcomes., Conclusions: Staged buccal mucosa graft urethroplasty is a suitable technique for salvage urethroplasty. Complications after second stage were seen in approximately a third of patients, mainly those with fibrotic/indurated grafts., (Copyright © 2011 American Urological Association Education and Research, Inc. Published by Elsevier Inc. All rights reserved.)

Objective: There is a paucity of literature on a definition or set criteria evaluating urethral plate (UP) quality. We sought to determine whether pediatric urologists are in agreement in their assessment of UP quality., Materials and Methods: A cohort of 21 pediatric urologists attending a national annual meeting were surveyed with a questionnaire inquiring about practice patterns and perceived impressions of UP quality. Nineteen sequentially projected, standardized, digital photographs, depicting plates with variable meatal locations, were presented. Intra- and inter-rater agreement among pediatric urologists was estimated by calculating the Kappa statistic (kappa)., Results: Thirty percent of respondents had more than 15years of practice and one-third repair 10 or more hypospadias per month. Measurement of level of agreement in the impression of UP quality of the 18 projected photographs revealed poor inter-rater agreement (kappa=0.06, P=0.0003), which was not improved by focusing on particular meatal locations or surgeon experience., Conclusions: Despite the inherent shortcomings of digital photography, this study highlights the potential subjectivity and lack of agreement on UP quality. Disagreement seems to be present irrespective of level of the defect or surgeon experience. Setting standards and improving agreement is likely to enhance reporting and interpretation of data in hypospadias studies., (Copyright (c) 2010 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.)

Purpose: The 2 main approaches to correct severe ventral curvature are dorsal plication of the corpora and ventral corporeal lengthening by tunica albuginea patching. Controversy persists since neither technique has been proved to be superior to the other with respect to initial or long-term outcome. However, to our knowledge a direct comparison of outcome of these 2 procedures has not been previously reported., Materials and Methods: A retrospective review of the records of 100 consecutive patients who underwent repair of penoscrotal or more proximal defects from 1996 to 2004 was performed. Children were divided into 2 groups, including group 1-32 who underwent a ventral penile lengthening procedure and group 2-68 who underwent dorsal plication. Meatal location, preoperative testosterone stimulation, severe ventral curvature (greater than 45 degrees) at the beginning of operation and after degloving, proximal ventral dissection, urethral plate transection and recurrent ventral curvature were compared between the 2 groups., Results: Mean age was 17 months (range 9 to 56) in patients with ventral penile lengthening and 17.8 months (range 10 to 58) in patients with dorsal plication. Mean followup was 65 (range 29 to 120) and 62 months (range 30 to 116), respectively. Of the 32 group 1 children 30 (93.7%) had penoscrotal or more proximal hypospadias vs 57 of the 68 (83.8%) in group 2. Three of the 32 children who underwent ventral penile lengthening had recurrent ventral curvature vs 19 of the 68 who underwent dorsal plication (9.4% vs 27.9%, p = 0.03). On multivariate analysis dorsal plication remained significantly associated with recurrent ventral curvature independently of the other factors (OR 4.56, 95% CI 1.14-18.28, p = 0.03)., Conclusions: Dorsal plication was more often associated with recurrent ventral curvature compared to ventral penile lengthening on univariate and multivariate analysis. Future studies adjusting for proximal ventral dissection and urethral plate transection are necessary to further elucidate the role of each technique in the correction of severe ventral curvature in children with proximal hypospadias.

Purpose: There is ongoing controversy regarding optimal treatment for severe ventral curvature. It has been suggested that ventral corporeal lengthening may be associated with recurrent curvature and erectile dysfunction. To further assess these issues we reviewed our experience with ventral penile lengthening for correcting the severe ventral curvature associated with proximal hypospadias., Materials and Methods: We reviewed the records of 38 boys with severe hypospadias and congenital ventral curvature greater than 45 degrees who were treated at our institution from 1995 to 2004 with placement of a flap or graft in the corporeal bodies to straighten the phallus. Of the patients 21 had perineal and 17 had penoscrotal hypospadias, including 22 with associated penoscrotal transposition and/or bifid scrotum and 6 with ambiguous genitalia. Testosterone stimulation before surgery was given in 11 children at surgeon discretion., Results: Median age at surgery was 15 months. The urethral plate was divided in 94.7% of patients. A tunica vaginalis flap was used alone in 23 cases and associated with dura, pericardium or small intestinal submucosa in 8, 2 and 1, respectively. The remaining 4 patients underwent ventral grafting alone, including lyophilized dura in 1, pericardium in 1 and dermis in 1. Urethral reconstruction was achieved by the transverse island flap technique or 1 of its modifications in 34 children. Four boys underwent a 2-stage procedure. Followup available on 35 of 38 patients was 1 to 11 years (median 5.3). Recurrent ventral curvature in 5 of 35 patients was mild in 1 and clinically significant, requiring re-intervention, in 4. Four of 9 patients (44.4%) who underwent corporeal grafting with lyophilized dura had recurrent ventral curvature vs 1 of 23 (4.3%) who had a tunica vaginalis flap (chi-square 5.14, p = 0.02). At last followup straight erections were documented by patients and/or parents in 30 of 35 children (85.7%)., Conclusions: The short-term outcome of ventral penile lengthening using tunica vaginalis flap alone for correcting severe chordee is favorable with a 95% success rate. Dural grafts were associated with a higher risk of recurrent ventral curvature compared to tunica vaginalis flaps. Although most of our patients were not yet adults, when chordee and erectile dysfunction may become apparent, we believe that tunica vaginalis flap repair is a good option for correcting severe ventral curvature.

Purpose: Despite being the dominant technique for repair of distal hypospadias, application of the tubularized incised plate approach for penoscrotal hypospadias remains controversial. We report our experience with severe hypospadias, comparing tubularized incised plate to transverse island flap onlay urethroplasty., Materials and Methods: We retrospectively reviewed consecutive patients with penoscrotal hypospadias presenting between 1998 and 2006. Based on surgeon preference 35 children underwent tubularized incised plate and 40 underwent onlay urethroplasty. Penoscrotal transposition and degree of ventral curvature, type of ventral curvature repair, complication rate, postoperative uroflowmetry pattern in toilet trained patients and number of reoperations were compared between the 2 groups., Results: Mean patient age at surgery was 17 months (range 9 to 91) for tubularized incised plate urethroplasty and 17.8 months (10 to 58) for the onlay procedure. Urethroplasty was performed over an 8Fr catheter in all patients. With mean followups of 30 months (range 6 to 74) and 38.8 months (16 to 80) the overall complication rates were 60% and 45% for the tubularized incised plate and onlay procedures, respectively. Fistula occurred in 15 patients and repair breakdown in 3 patients (total 51.4%) treated with tubularized incised plate repair, compared to 8 and 2 patients, respectively (25%), treated with onlay repair (p = 0.01). Fistula location also differed significantly between the 2 groups, with proximal fistulas occurring in 11 of 15 tubularized incised plate repairs (73.3%) vs 2 of 8 onlay repairs (25%, p = 0.02). Recurrent ventral curvature was more frequent after onlay urethroplasty (5.7% vs 12.5%, not significant). At a mean age of 5.1 years a plateau uroflow curve (vs normal bell curve) was observed in 16 of 24 children (66.7%) who underwent tubularized incised plate repair and in 7 of 21 (33.3%) who underwent onlay repair (p <0.01)., Conclusions: In this series the overall complication rate was similar for tubularized incised plate and onlay urethroplasty. Despite similar urethroplasty calibers, the uroflow curves and fistula positions in patients undergoing tubularized incised plate repair suggest that the neourethra distal to the fistula may be relatively narrow, creating flow resistance and leading to proximal fistula. Longer followup and close monitoring are needed before embracing one approach over the other.

Purpose: Considerable controversy exists regarding the optimal surgical technique for the repair of mid shaft and proximal hypospadias. We sought to evaluate differences in surgical preferences among an international cohort of pediatric urologists., Materials and Methods: An anonymous questionnaire containing relevant demographic data as well as choices of technique to repair 5 representative hypospadias cases was developed and administered., Results: Of 121 pediatric urologists contacted 101 completed the survey, representing an 83% response rate. The majority were full-time academic pediatric urologists who performed 6 to 10 hypospadias surgeries monthly. A total of 92 respondents (confidence interval [CI) 0.84 to 0.96) preferred the tubularized incised urethral plate (TIP) technique for the repair of distal hypospadias. Similarly, 82 (CI 0.72 to 0.88) preferred TIP for the repair of mid shaft hypospadias. The 2 most common techniques for repair of proximal hypospadias without chordee, preferred by 43 correspondents each (CI 0.33 to 0.53), were TIP and transverse island flap (TVIF) onlay. For repair of moderate (30-degree to 40-degree) chordee dorsal plication was preferred by 82 respondents, while a ventral approach was preferred by 12. When moderate chordee was associated TVIF onlay was preferred by 35 (CI 0.26 to 0.45) and TIP by 24 respondents (CI 0.16 to 0.34). For severe chordee (greater than 50 degrees) 31 respondents preferred dorsal plication, while 68 chose some form of ventral repair. Among the respondents 37 approach proximal hypospadias associated with severe chordee using a staged procedure, while 40 use a single stage procedure using a TVIF tube (CI 0.30 to 0.50). Using Spearman's rank correlation coefficient, no significant correlations were identified between respondent practice demographics and choice of repair for each hypothetical hypospadias case., Conclusions: In this cohort of pediatric urologists we observed that the majority prefers TIP to repair distal and mid shaft hypospadiac defects. Significant variability exists for preferred technique for proximal hypospadias and chordee correction. These results support the need for prospective trials comparing techniques for the repair of proximal hypospadias.