BERKELEY, CA (UroToday.com) - A large surgical armamentarium exists for the repair of hypospadias. Nevertheless, it remains an arena of controversy regarding which repair is optimal. This study by Cook et al coalesced the experience of an international cohort of practicing pediatric urologists to see which hypospadias and chordee repair techniques they are most commonly utilizing.

The group distributed through personal communication and e-mails a 9-item questionnaire detailing important demographic data and 5 hypothetical hypospadias cases of varying severity to 121 practicing pediatric urologists. A number of common repair techniques for each case were available as choices, and participants were given the opportunity to report any other technique used but not otherwise specified within the questionnaire. The results were tabulated and correlations made (using Spearman's rank correlation coefficient) between chosen technique and number of hypospadias repairs performed monthly, type of practice and number of years in practice. Confidence intervals (95% CI) were performed on the chosen repair techniques for each hypothetical hypospadias case.

101 questionnaires were returned, resulting in an 83% response rate. All returned questionnaires were complete. The respondents were from a number of countries in North and South America, and Europe. Almost 60% had been practicing for more than 10 years, indicating an experienced cohort of pediatric urologists. A total of 61 of the 101 respondents practiced 75% to 100% pediatric urology, while 25 and 15 estimated their practices consisted of 50% to 75% and less than 50% pediatrics, respectively. The majority of respondents practiced full-time academic urology. More than 85% of those who ranked their practice as consisting of 75% to 100% pediatric urology did so in a full-time academic environment. Of the participants 48 reported performing 1 to 5 hypospadias surgeries, 35 reported 6 to 10 surgeries, 17 reported 11 to 15 surgeries and 1 reported 16 to 20 surgeries monthly.

The following data was determined for the listed entities:

1. Distal hypospadias without chordee. 92% prefer using tubularized incised urethral plate (TIP) for the repair of distal hypospadias without chordee (CI 0.84 to 0.96). 4% (CI 0.01 to 0.1) use the Mathieu (flip-flap) technique, 3% (CI 0.006 to 0.09) prefer the TVIF onlay and 1% (CI 0.002 to 0.07) perform either a meatal advancement and glanuloplasty or urethral advancement procedure.
2. Mid shaft hypospadias without chordee. The results were similar to the previous category.
3. Proximal hypospadias without chordee. The underlying theme seemed to be that dorsal plication of a chordee less than 50 degrees was adequate where anything more seemed to favor a graft.

Based on their findings, the group concluded that the TIP procedure has become the most commonly used technique for the repair of distal and mid shaft hypospadias. More proximal defects, with or without associated chordee, continue to be repaired with a various number of 1 and 2-stage techniques. The group stated that personal preference based on experience and training, is the most important factor pediatric urologists consider for repairing proximal hypospadias. I agree and continue to be a firm believer that successful hypospadias surgery depends upon experience and refinement of technique that accompanies that experience.

The Journal of Urology, 174(6): 2354-2357, December 2005