1506 LETTERS TO THE EDITOR

5. Masood J, Panah A, Zaman F, Papatsoris A, Junaid I and Buchholz N: 6. Sharer W, Grayhack JT and Graham J: Palliative urinary diversion for
A cost-effectiveness model for long-term stenting of ureteric strictures malignant ureteral obstruction. J Urol 1978; 120: 162.
with Memokath 051. Presented at annual meeting of British Associ-
ation of Urological Surgeons, Section of Endourology, London, United 7. Rainwater LM, Leary FJ and Rife CC: Transureteroureterostomy with
Kingdom, May 15–16, 2008. cutaneous ureterostomy: a 25-year experience. J Urol 1991; 146: 13.

Re: The Pediatric Penile Perception Score: An Instrument for

Patient Self-Assessment and Surgeon Evaluation After
Hypospadias Repair
D. M. Weber, V. B. Schönbucher, M. A. Landolt and R. Gobet
J Urol 2008; 180: 1080 –1084.

To the Editor: The authors are to be commended for attempting to develop an objective evalu-
ation of the results of hypospadias surgery with the Pediatric Penile Perception Score (PPPS)
survey. The authors report that boys 6 to 17 years old who had undergone reconstructive
hypospadias surgery demonstrated satisfaction with the appearance of the genitals that was
nearly identical to boys who were born without hypospadias.
In a study of 56 men with uncorrected hypospadias we found that 95% (53 of 56) stated that
they were satisfied with the appearance of the genitals and 32% (18) did not appear to be aware
that they had an abnormality of the genitals.1 We concluded that satisfaction with the appearance
of the penis does not necessarily depend on the ability of a surgeon to place the urethral meatus at
the mid glans. While our survey was not as rigorous as that conducted using the PPPS, it had the
distinct strength of having 100% participation. A convincing test of the cosmetic success of hypospa-
dias surgery would be to compare individuals who have undergone corrective surgery in late
childhood and adulthood, so that satisfaction could be compared before and following surgery.
We agree with the authors that future evaluations of patients following hypospadias
surgery should include assessment of urinary flow. Of concern is the report of Wolffenbuttel
et al that patients who have undergone tubularized incised plate repairs have lower urinary
flow rates than preoperatively, suggesting that the surgery causes obstruction in the area of
the glans penis.2 In essence, attempts to improve the cosmetic appearance of the penis may
worsen flow characteristics.
Respectfully,
Peter R. Dodds
Department of Surgery
Norwalk Hospital
34 Maple St.
Norwalk, Connecticut 06856

Reply by Authors: Dodds et al demonstrated in their remarkable study that the majority of
patients were satisfied with the appearance of the penis despite the uncorrected hypospadi-
as.1 Recent studies by our research group at University Children’s Hospital Zurich suggest
that the health related quality of life and psychosexual development of boys and adolescents
who have undergone surgical correction of hypospadias do not correlate with the surgical
result.3,4 These publications raise the question of whether the repair of (distal) hypospadias
improves patient happiness at all. The study that compares health related quality of life and
psychosexual function of men with and without correction of the hypospadias has yet to be
performed.

1. Dodds PR, Batter SJ, Shield DE, Serels SR, Garafalo FA and Maloney 3. Schonbucher VB, Landolt MA, Gobet R and Weber DM: Health-related
PK: Adaptation of adults to uncorrected hypospadias. Urology 2008; quality of life and psychological adjustment of children and adoles-
71: 682. cents with hypospadias. J Pediatr 2008; 152: 865.

2. Wolffenbuttel KP, Wondergem N, Hoefnagels JJ, Dieleman GC, Pel 4. Schonbucher VB, Landolt MA, Gobet R and Weber DM: Psychosexual
JJ, Passchier BT et al: Abnormal urine flow in boys with distal development of children and adolescents with hypospadias. J Sex
hypospadias before and after correction. J Urol 2006; 176: 1733. Med 2008; 5: 1365.