EUROPEAN UROLOGY 60 (2011) 1190–1192
available at www.sciencedirect.com
journal homepage: www.europeanurology.com
Platinum Priority – Editorial and Reply From Authors
Referring to the article published on pp. 1184–1189 of this issue
Hypospadias Classification and Repair: The Riddle of the Sphinx
Antonella Giannantoni *
Department of Urology and Andrology, University of Perugia, Opsedale Santa Maria della Misericordia, Perugia, Italy
Hypospadias is the most common congenital anomaly of
the penis, affecting 0.4–8.2 of 1000 live male babies [1]. The
term hypospadias stems from two Greek words: hypo, which
means ‘‘below,’’ and spadon, which means ‘‘hole.’’ The
anomaly is characterized by a urethral meatus ectopically
located proximal to the normal place on the ventral side of
the penis. Different anatomic presentations can be ob-
served. The position of the urethral meatus can be classified
as anterior or distal (glandular, coronal, or subcoronal;
60–65% of cases), middle (midpenile; 20–30% of cases),
or posterior or proximal (posterior penile, penoscrotal,
scrotal, or perineal; 10–15% of cases) [2]. The subcoronal
position is the most common. Proximal cases are considered
severe and can be associated with chordee [2]. The term
chordee derives from the Greek word chorda, which means
‘‘string’’ or ‘‘rope’’ and indicates the ventral curvature of the
penis.
Clinical symptoms vary and depend on the severity of the
disease. In mild hypospadias with a urethral meatus located
on the glans, a normal urinary flow can be maintained. In
cases with a stenotic meatus, a weak urinary flow can be
observed. Children with proximal hypospadias with penile
curvature might not be able to void while standing.
Actually, we do not know precisely what degree of penile
curvature in children will inhibit sexual intercourse in
adulthood or what the long-term psychosexual outcome
will be in these patients.
Many questions still arise on several aspects of the
disorder, such as how to objectively define the severity of
the disease, what is the real benefit of preoperative
hormonal stimulation, and particularly, what is the best
surgical correction to adopt according to type and severity
of hypospadias [3]. Generally speaking, the assessment of
severity is based on meatal position, quality of the urethra
and urethral plate, and presence or absence of penile
DOI of original article: 10.1016/j.eururo.2011.08.031
* Department of Urology and Andrology, University of Perugia, Opsedale Santa Maria della Misericordia, Perugia, Italy. Tel. +39 075 5784416;
Fax: +39 075 5784416.
E-mail address: agianton@libero.it.
0302-2838/$ – see back matter # 2011 European Association of Urology. Published by Elsevier B.V. All rights reserved.
curvature. As suggested by Snodgrass et al, patients with
hypospadias present with a continuum of abnormalities
ranging from simple glanular forms to perineal presenta-
tions with different degrees of penile curvature, and it is not
clear in what situation the adjective severe should be
applied [3]. The assessment of severity is obviously
influenced by subjective judgment, which can differ among
surgeons. Is it possible to create a more objective severity
classification taking into account meatal position, quality of
urethra and urethral plate, and presence or absence of
penile curvature? Or as some maintain, can the assessment
of hypospadias severity be adequately performed only in
the operating room [3]? Indeed, the solution is of great
importance, as the choice of surgical repair is based on it.
While the goals of hypospadias surgery have been clearly
stated—create a functional penis adequate for sexual
intercourse, produce a correct urethral reconstruction to
allow the patient to stand to urinate, and offer satisfactory
cosmetic results [4]—the choice of urethroplasty is still a
matter of debate. Many types of urethroplasty can be
performed with the goal of adequately correcting the
congenital disorder (Duplay/tubularized incised plate [TIP],
Mathieu, onlay, Koff, Bracka, Duckett, and Koyanagi/
Hayashi) [3,5]. In addition, Nesbit, tunica albuginea plica-
tion, ventral plasty, and many other techniques have been
developed to correct the chordee [3,5]. To date, also in
systematic reviews of hypospadias corrections, no ure-
throplasty technique appears to be definitively superior
[4,6]. What we know is that in most cases, hypospadias can
be repaired in a single-stage operation that includes meatal
advancement and glanuloplasty (MAGPI), glans approxi-
mation procedure, and tubularization following incision of
the urethral plate (TIP) [5]. A two-stage operation may be
required for more severe forms of penoscrotal or perineal
hypospadias [5].
 EUROPEAN UROLOGY 60 (2011) 1190–1192
But what is the actual evidence from the literature on the
preferred method of urethroplasty by surgeons to correct
primary hypospadias? In a previously reported North
American survey, Cook et al. found that 90% and 83% of
pediatric urologists used a TIP procedure to repair distal and
midshaft hypospadias without penile curvature, respec-
tively, and only 6% preferred an onlay island flap [7]. In that
study, the preferred surgical procedure to correct proximal
hypospadias without penile curvature was, again, one-stage
repair (TIP repair and onlay island flap repair were each
preferred by 43% of participants). When considering the
preferred surgical urethroplasty to correct proximal hypo-
spadias with severe penile curvature, 40% of urologists in
that study preferred the Duckett repair, 11% preferred the
onlay island flap, and 3% preferred the TIP repair [7].
What emerges from the interesting study of Springer
and coauthors is consistently different [8]. The authors
tried to identify actual international trends in the
management of hypospadias by inviting pediatric urolo-
gists, pediatric surgeons, urologists, and plastic surgeons
worldwide to participate in an anonymous multiple-choice
online questionnaire. Completed questionnaires were
obtained from 377 participants from 68 countries. From
the results, it appeared that in distal hypospadias (sub-
coronal to midshaft), TIP repair was the preferred method
of 52.9–71.0% of participants. MAGPI was the preferred
method to correct glandular hypospadias. The two-stage
repair was the preferred method to correct proximal
hypospadias for 43.3–76.6% of participants, which is in
contrast to the results of the North American survey in
which one-stage procedure was the method of choice [7].
These data are also of particular interest considering the
recently published excellent long-term results of island
flaps or tubes in the correction of proximal hypospadias,
which should convince surgeons to use these techniques in
hypospadias repair [9].
Once again, we have to admit that publications do not
represent what happens in everyday clinical practice, and
there may be additional factors influencing the choice of
surgical technique in hypospadias correction. As suggested
by Springer et al, ‘‘personal taste, training, experience and
personal success’’ lead surgeons every day to choose a
proper surgical technique for hypospadias repair, and
Platinum Priority
Reply from Authors re: Antonella Giannantoni. Hypospa-
dias Classification and Repair: The Riddle of the Sphinx.
Eur Urol 2011;60:1190–1
Alexander Springer *
Department of Pediatric Surgery, Medical University of Vienna, Austria
DOIs of original articles: 10.1016/j.eururo.2011.08.031,
10.1016/j.eururo.2011.08.057
* Department of Paediatric Urology, Leeds Teaching Hospitals, Leeds, UK.
Tel. +44 (7412) 690107.
E-mail address: alexander.springer@meduniwien.ac.at.
1191
surprisingly, this choice is not influenced by the personal
number of surgical repairs per year [8].
We all well know that to establish the best treatment for a
pathologic condition requires evaluation of the reported
results. To date, the reports on outcome of hypospadias repair
are sparse, and results of prospective studies with long
follow-up are still lacking. In addition, functional and
cosmetic outcomes are generally assessed in a subjective
manner, and a standardized evaluation of these outcomes is
urgently needed.
Use of the same language is necessary, particularly in the
surgical field. We need to better define moderate and severe in
regard to penile curvature and high quality in regard to
urethral plate. Perhaps having more reliable results and using
a more comprehensive classification could help solve the
Riddle of the Sphinx in hypospadias classification and
correction.
Conflicts of interest: The author has nothing to disclose.
References
[1] Baskin LS, Ebbers MB. Hypospadias: anatomy, etiology, and tech-
nique. J Pediatr Surg 2006;41:463–72.
[2] Leung ARC, Robson WLM. Hypospadias: an update. Asian J Androl
2007;9:16–22.
[3] Snodgrass W, Macedo A, Hoebeke P, Mouriquand PDE. Hypospadias
dilemmas: a round table. J Pediatr Urol 2011;7:145–57.
[4] Castagnetti M, El-Ghoneimi A. Surgical management of primary severe
hypospadias in children: 20-year review. J Urol 2010;184:1469–74.
[5] Hayashi Y, Kojima Y. Current concepts in hypospadias surgery.
Int J Urology 2008;15:651–63.
[6] Snodgrass W. Hypospadia reporting—how good is the literature?
J Urol 2010;184:1255–6.
[7] Cook A, Khoury AE, Neville C, Farhat WA, Pippi Salle JL. A multicenter
evaluation of technical preferences for primary hypospadias repair.
J Urol 2005;174:2354–7.
[8] Springer A, Krois W, Horcher E. Trends in hypospadias surgery:
results of a worldwide survey. Eur Urol 2011;60:1184–9.
[9] Snodgrass W, Bush N. Tubularized incised plate proximal hypospa-
dias repair: continued evolution and extended application. J Pediatr
Urol 2011;7:2–9.
doi:10.1016/j.eururo.2011.08.057
We appreciate the thoughtful editorial by Dr. Giannantoni
[1] regarding our article about an international hypospadias
surgery survey [2]. There are still many questions to be
asked. In a field where hardly any valid data exist besides
retrospective studies and reports of single surgeons or
single centers, we thought it would be particularly exciting
to have a close look at worldwide current trends in
hypospadias surgery.
Depending on personal concepts of surgical correction,
surgeons define severity of hypospadias based on degree
of chordee, hypoplasia of ventral tissues, need for transection