Accepted Manuscript

Penile appearance after hypospadias correction from a parent’s point of view:

comparison of the hypospadias objective penile evaluation score and parents penile
perception score

Dr Bernhard Haid, Tanja Becker, Mark Koen, Christoph Berger, Christa Strasser,
Judith Roesch, Christian Zniva, Josef Oswald
PII: S1477-5131(15)00437-4
DOI: 10.1016/j.jpurol.2015.10.010
Reference: JPUROL 2086

To appear in: Journal of Pediatric Urology

Received Date: 24 August 2015

Accepted Date: 31 October 2015

Please cite this article as: Haid B, Becker T, Koen M, Berger C, Strasser C, Roesch J, Zniva C, Oswald
J, Penile appearance after hypospadias correction from a parent’s point of view: comparison of the
hypospadias objective penile evaluation score and parents penile perception score, Journal of Pediatric
Urology (2016), doi: 10.1016/j.jpurol.2015.10.010.

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 ACCEPTED MANUSCRIPT

Penile appearance after hypospadias

correction from a parent’s point of view:
comparison of the hypospadias objective
penile evaluation score and parents

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penile perception score

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Bernhard Haida,*, Tanja Beckera, Mark Koena, Christoph Bergera, Christa Strassera, Judith

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Roescha, Christian Znivab, Josef Oswalda

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Department of Pediatric Urology, Hospital of the Sisters of Charity, Linz, Austria
b
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Department of Clinical Psychology, Hospital of the Sisters of Charity, Linz, Austria
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*Corresponding author: Dr Bernhard Haid, Department of Pediatric Urology, Hospital of the

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Sisters of Charity, Seilerstätte 4, 4020 Linz, Austria. Tel.: 0043 732 7677 4323.
E-mail address: bernhard.haid@bhs.at
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 ACCEPTED MANUSCRIPT

Summary

Introduction: There is scarce information on the parents’ views of the cosmetic outcome
after hypospadias surgery compared with pediatric urologists’ views, using objective and
validated scoring systems.

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Objective: This study aimed to evaluate whether the results of the hypospadias objective
penile evaluation (HOPE) score are transferable to parents’ satisfaction, as measured by the

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pediatric penile perception score (PPPS).

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Study design: This was a prospective evaluation of 42 boys after hypospadias correction.
Two surgeons independently assessed the HOPE score and the PPPS score, and the parents
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completed four questions specifically designed by a psychologist. The parents’ questionnaire
was mailed back to the study authors. A total of 29 (69.9%) full datasets were available for
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evaluation (two (6.9%) glandular, 20 (68.9%) coronal, six (20.6%) penile and one (3.4%)
scrotal hypospadias, median age 15.0 months).
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Results: The parents’ assessments of the cosmetic results were worse than the surgeons’
assessments (81.13% (PPPS) vs. 92.81% (HOPE) of the respectively possible highest score,
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P<0.0001). There was no correlation between parents’ and surgeons’ assessments judging the
respective high-score percentages (r=0.1358, Pearson). If only one question on the
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‘satisfaction with the general appearance’ was considered, there was no significant difference
between parents and surgeons (P=0.6334). All 58 parents (100%) were convinced that surgery
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led to a better cosmetic appearance of their sons’ genitalia, although both mothers and fathers
perceived the operation to be a major encumbrance (fathers 3.62 vs. mothers 3.97 on a scale
from 0-6, P=0.22).

Discussion: Whereas there was no significant difference between surgeons and parents when
considering the judgment of general appearance of the penis, there was a difference when
validated tools were used. The focus of the HOPE questionnaire lies on features that can be

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influenced by surgery. Possibly, the PPPS, which has more general questions and assessments
(e.g. for penile length), gives a more realistic impression from a parent’s point of view.
Foreskin removal, which was performed on all of the boys, was unlikely to be a confounding
factor because the parents had been informed pre-operatively. The operation itself, even for
the relatively distal hypospadias in this group of patients, was perceived as a major
psychological burden.

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Conclusion: Using validated tools and in direct comparison with the highest possible score of

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either tool (HOPE or PPPS), the cosmetic results were judged to be significantly more
optimistic by the surgeons than the parents. The HOPE score results therefore may not be

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transferred uncritically to the parents’ views on the cosmetic results.

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Keywords: HOPE score; PPPS; Hypospadias; Cosmetic outcome; Parents
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Introduction

With a frequency of 1:300 male births, and varying largely in different countries [1],
hypospadias is one of the most common congenital malformations. With the evolution of
surgical techniques during the past decades, although there are still problems in long-term
follow-up [2], surgical results have improved and have less functional postoperative problems

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[3-5]. Therefore, the quality of the cosmetic outcome is gaining more importance. This is
especially as, nowadays, perception of genital cosmesis tends to be more differentiated and
cosmetic outcomes after hypospadias surgery have become more important [6].

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Boys that have undergone unsatisfactory hypospadias correction have a worse genital self-
perception and are more often sexually inhibited. Other known problems involved with poor
cosmetic outcomes are an impaired self-perception and a pathologically increased sense of

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shame [7,8] or worse school performance [9]. When evaluated in adulthood, patients with
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initially severe hypospadias are less satisfied with their genital cosmesis compared with men
without hypospadias [10], and more frequently report functional problems [11]. There are
data on different perceptions of outcomes, comparing surgeons’ and patients’ views, showing
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that surgeons tend to be more satisfied by their results compared with patients [12].
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Concerning the perception of ‘a good looking penis’, this implies subjective issues. As
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recently reported [13], women who were asked about their opinions on the cosmetic result
after distal hypospadias repair deemed meatal position to be the least important aspect. This is
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most certainly in contradiction with surgeons’ opinions where, especially in distal

hypospadias, a slit-like meatus at the tip of the glans is a major objective of hypospadias
repair.
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Concerning the parents’ opinions (who are deeply psychologically involved in the decision-
making process for surgery) of the cosmetic results, there are scarce data available [14].

During the last few years, standardized and prospectively validated score systems for the
assessment of cosmetic results after hypospadias correction have been presented. As far as
patients and parents are concerned, the pediatric penile perception score (PPPS) was first
presented by Weber et al. in 2008 [14]. It can be used to objectively assess the cosmesis of the
infantile male external genitals, which also includes the parents’ point of view.

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Concerning the surgeons’ assessments, there are different tools available. However, there are
no generally accepted and standardized criteria for evaluation. As early as 1980, Horton et al.
[15] reported on a classification of complications after hypospadias operations. Baskin et al.
[16] reported on standardized assessment of results using photographs, however, this didn’t
result in a reproducible score and not only assessing for cosmesis but also for complications.

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In 2001, Holland et al. [17] proposed a method for assessing results by using a standardized
system to report on outcomes and complications – the HOSE (hypospadias objective scoring

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evaluation) score. To match the PPPS, however, there was a need for a prospectively
validated, standardized tool to assess the cosmetic outcome after finished hypospadias

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correction, with no reference to complications. Therefore, the present study chose the
hypospadias objective penile evaluation (HOPE) score [18] that has been prospectively
validated and includes all relevant cosmetic aspects that are surgically influenced.

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The aim of the present study was to assess the parents’ perspectives on the cosmetic results
after hypospadias correction, as well as to evaluate to what extent the HOPE score results are
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comparable to the parents’ assessments of postoperative cosmesis (PPPS).

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Patients and Methods

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A total of 42 patients who underwent hypospadias correction were prospectively evaluated

after informed consent at their control visit in the present outpatient department. Inclusion
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criteria were: a completed hypospadias correction without further planned intervention,

complete wound healing, and an operation no longer than 18 months prior to the time of
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inclusion into the study.

The local ethics committee approved the study protocol (EK 42/13).

Two surgeons (one of them was the operating surgeon for 13 patients) independently
completed the hypospadias objective penile evaluation (HOPE) score questionnaire using the
photographic panels as described in the original publication [18]. One question on their

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general impression of the appearance of the penis was supplemented (Appendix A ‘Surgeons
Questionnaire’).

The parents were asked to fill in a questionnaire, which was identical for mothers and fathers,
independently at home and mail it back to the department. The parents’ questionnaire
included the parents’ version of the pediatric penile perception score (PPPS) [14]. Four

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additional questions were added concerning their opinions on the psychological burden
involved with having their sons operated on, as well as any possible psychosexual

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consequences of the operation’s cosmetic outcome on their son’s future. Those questions
were designed with the help of the institutional children’s psychologist (CZ) (Appendix B

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‘Parental Questionnaire’).

A total of 29 (69.0%) parents mailed back a completed and evaluable questionnaire. All

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parents who didn't mail back (n=9) were contacted by telephone: five promised to mail the
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questionnaire but did not, four refused to mail it back and withdrew their consent to study
participation, and four mailed back an unusable partly or not-filled-in questionnaire.
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Of the 29 available data sets, two (6.9%) patients had a glandular, 20 (68.9%) a coronal, six
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(20.6%) a penile, and one (3.4%) a scrotal hypospadias. Their median age at operation was
15.0 months; the median interval between operation and inclusion into the study was 5.1
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months. In 89.6% (26 patients) of the cases, one operation was performed; in 10.4% (three
patients), two operations were performed.
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A tubularised incised plate (TIP) repair was performed in 26 patients (89.7%), one patient
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(3.4%) underwent a Thiersch-Duplay procedure, and two patients (6.8%) had a meatal
advancement and glanduloplasty (MAGPI). The foreskin was removed in all cases. If any
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urethral reconstruction was performed, a subdartos flap was used to cover the neourethra
(Table 1).

Data were then anonymized and fed into an Excel data sheet; statistical analysis was carried
out using Prism 6.0 for Mac (GraphPad Software Inc.). Besides descriptive statistics, paired t-
tests were used for comparison of parametric values and Wilcoxon matched-pairs signed rank
tests for non-parametric values. For correlation analysis, a non-parametric two-tailed

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Spearman analysis was carried out for non-parametric data and a Pearson analysis for
parametric data.

Results

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Surgeons
The mean total HOPE score was 46.1 of a maximum possible score of 50. This accounts to

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92.81% of the possible maximum score (Fig. 1.A).

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There was no significant difference (P=0.13) between operating (mean score 47.15 95% CI
45.18-49.13) and non-operating surgeon (mean score 45.9 95% CI 43.02-48.03) in those cases

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(n=13) where the operating surgeon was involved in the assessment of the HOPE score (Fig.
1.B). There were also no significant differences between the single HOPE items between the
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judging surgeons (data not shown).
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Additional to the HOPE score, the surgeons were asked how they generally liked the
appearance of the penis, in the exact words as used in the parents’ version of the PPPS. In
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48.2% (28) single judgments, the surgeons were very satisfied by the general appearance,
44.8% (26) were satisfied, and 6.9% (four) were unsatisfied. The results correlated well
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between the two surgeons assessing each case (r=0.509, P=0.005).

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Parents
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The mean PPPS score was 14.6 (mothers 14.8, fathers 14.4) of a maximum possible score of
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18. This accounted to a mean of 81.1% (mothers 82.3%, fathers 79.9%) of the possible
maximum score (Fig. 2.A).

There was no statistically significant difference between mothers and fathers, neither in the
total score nor looking at the single PPPS items. Correlation analysis showed good correlation
(r>0.4 for all items reaching significance) between fathers and mothers (Fig. 2.B).

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The burden of operation was assessed on a 6-point Likert scale (0 = no burden, 6 = heavy
burden). Mothers rated to a mean of 3.96 (95% CI 3.47-4.45), fathers to 3.62 (95% CI 3.02-
4.21). There was no statistically significant difference (P=0.218) (Fig. 3).

All parents (n=58) stated that the appearance of their son’s penis was better after the operation
compared to before: 91.4% (53/58) were convinced that their sons would be satisfied with the

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appearance of their penis in the future; 5.1% (3/58) stated that the self-esteem of their sons
could be constrained by the cosmetic appearance of their penis.

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As to foreskin removal, 96.6% of the parents (56/58) stated that pre-operative information on

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foreskin removal was sufficient and met their needs to fully understand what the penis would
look like after circumcision. Two fathers who stated that they weren’t adequately informed
were not present at the pre-operative parental information session, which may explain their

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lack of information.
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Comparison
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In order to assess the differences between the two scoring tools, the percentage of the
respective highest possible score was assessed. Comparison (surgeons HOPE 92.81% vs.
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parents PPPS 81.13%) revealed a statistically significant difference of 10.68% (P<0.0001)

(Fig. 4.A).
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There was no correlation between parents’ and surgeons’ assessments, judging by the
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respective high-score percentages (r=0.1358, 95% CI –0.1269-0.3808, p 0.309, Pearson

correlation coefficient).
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The answers to the single question about how parents or surgeons judge the general
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appearance of the penis (very satisfied, satisfied, unsatisfied, very unsatisfied) after
hypospadias correction revealed no significant difference (P=0.6334) (Fig. 4.B).

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Discussion

The most important end point concerning functional and cosmetic outcomes after hypospadias
correction is patient satisfaction. Parents, however, are deeply emotionally involved and
usually decide on the indication for a hypospadias correction when their child is young. In

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order to provide them with objective and reproducible information on the expected results,
parents’ and surgeons’ perceptions of cosmetic outcomes should be correlated. Moreover, if

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validated tools are used and the possible quality of cosmetic results is explained to parents
using data assessed by such tools, their results should be matched to the parents’ assessment.

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The HOPE score [18], which is used in the Dutch Hypospadias Database, is one of the largest
prospective efforts to record objective data on hypospadias surgery, and is currently the

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standard in judgment of cosmetic results after hypospadias operations. It has been
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prospectively validated and by the use of boards with photos presenting the relevant results
showed good intra- and interrater correlation. By judging single items (position of meatus,
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shape of meatus, shape of glans, shape of skin, torsion, and curvature) the total score gives a
judgment of the quality of the cosmetic result in respect to these criteria, which are influenced
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by hypospadias surgery.
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The PPPS [19], in contrast, which has been designed and validated for both patient and
parental use, assesses for comparable items (penile length, position and shape of the urethral
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opening, shape of the glans, shape of the penile skin, penile axis, and general cosmetic
appearance). However, ‘general appearance’ and penile length are also taken into account.
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Apparently, those logically relevant criteria from a parent’s point of view lead to a relevant
diminished sum score in the parents evaluated in the present study, which may explain the
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results.

Therefore, the HOPE score results and their possible implications on parents’ assessments
may not be useful for parental information without restrictions. In order not to raise
unrealistic expectations, they should be used cautiously in such context.

One possible confounding factor could be the foreskin removal leading to an appearance like
after circumcision, which for most of the parents could be unusual, as around 15% of all men
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are circumcised in Austria. In the present study population, two patients were Muslims. Of the
others, none had an obvious religious or cultural background connected to a modified
acceptance of circumcision. Recently, foreskin removal has been reported as an important
factor being connected to decisional regret after distal hypospadias operations [20]. In the
present study, two fathers (2/58 parents questioned, 3.4%) reported having not been
adequately informed on the routine removal of the foreskin carried out during hypospadias

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operations in the present department. Both fathers were not present at the pre-operative
counseling. Therefore, as no item in the PPPS directly refers to the foreskin, and the results of

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the general assessment of the penile cosmesis were no different between parents and
surgeons, it seems unlikely that foreskin removal influenced the study results.

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On the other hand, by simply judging the general appearance of the penis, as assessed by one
simple question, surgeons and parents agreed very well. This may prove that, from a

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surgeon’s point of view, criteria that cannot be directly influenced by surgery are relevant for
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the perception of postsurgical cosmesis. This is a point that clearly should be empathized in
parental information pre-operatively.
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The conclusion that hypospadias correction leads to an improvement in penile cosmesis is

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encouraging. However, this may have been an object of bias caused by the fact that all parents
had already gone through the stress of the operation with their children, and tended to
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positively transfigure their experiences. This factor appears to be important, especially in the
present group of children with mainly distal hypospadias, reflecting the ‘real life’ distribution
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of meatal localization, where cosmesis is an important part of the indication.

More than 90% of all parents did not believe that their sons might be subjected to problems
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with their sexual identification or self-confidence later in life due to hypospadias correction.
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There is literature showing that health-related quality of life (HRQoL) is diminished in boys
after hypospadias correction [7]. Interestingly, also in this paper, HRQoL from a mother’s
point of view, as well as psychological adjustment, did not differ from a control group. The
present results, with regard to the literature, suggest that parental estimations may be wrong
and parents consequently should be informed of the possible psychological consequences they
might underestimate themselves.

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In the present study, it was found that having a boy undergoing hypospadias correction
represented a considerable psychological burden to his parents. Recently, Lorenzo et al. [20]
reported on decisional regret after distal hypospadias operations by using standardized and
validated tools for measuring how parents think postoperatively about their decision to allow
their son to have the operation. They showed that a considerable number of parents regretted
their decision (41.4% ‘mild regret’, 8.6% ‘moderate-to-severe regret’). This should be

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considered during pre-operative parental information sessions. During pre-operative
conversations with the parents, surgeons may tend to present the forthcoming operation as

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much less dramatic, and the cosmetic outcome much better than is actually experienced. Even
distal hypospadias without frequent complications, as in the present cohort, may lead to major

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parental concerns. It has been shown for congenital heart disease [21] that the child’s illness
may lead to major impairments in the quality of life of the parents. Further studies are
warranted to assess how much this quality of life may be impaired by more complicated

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courses of difficult hypospadias corrections. It can only be speculated how the stress that
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parents experience during such operations may affect their relationship with their children.
There are, however, some reports on the possible negative consequences of stressful early
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childhood experiences on later parental educational conduct and the parent-child relationship
[22]. Moreover, post-traumatic stress reactions are common after childhood surgery and are
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most probably under-emphasized [23,24].

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One possible limitation of the study was the small number of 42 questioned parent/surgeon
pairs and 29 fully evaluable data sets. However, as this corresponded to 29 fathers and 29
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mothers as well as two surgeons per patient, it provides four data points (two PPPS and two
HOPE) per patient and 116 data points in total. Moreover, the main endpoint of the study – to
show a difference in absolute cosmetic appearance comparing both tools – was highly
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statistically significant on a paired t-test (P<0.0001) at this number of patients as were all
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other planned statistical tests. Additionally and importantly, the distribution of hypospadias
severity (meatal localizations) was representative of the (and most probably others as well)
patient spectrum (75.8% ‘distal’, 24.2% ‘proximal’ hypospadias), making the data meaningful
and representative for an average patient population.

The present study may have been further limited by being a single center evaluation and
biased by the fact that a number (n=9) of parents refused to participate, and their missing data
could have modified the end results.

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Conclusion

This study showed that the HOPE score might overestimate the quality of the cosmetic
outcome compared with the PPPS score. This should prompt a critical approach when

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reporting data on optimal cosmetic outcomes as measured by the HOPE score during pre-
operative parent counseling.

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Additionally, the results suggest that parents can be reassured pre-operatively and that there is

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a very high chance of being satisfied with the end result. The burden, however, involved with
hypospadias correction on the parents side should not be underestimated and information on
the possible concerns associated with relatively uncomplicated and distal cases, as in the

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present study, should be part of any pre-operative parent information.
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The authors certify that they have NO affiliations with, or involvement in, any organization or
entity with any financial interest or non-financial interest in the subject matter or materials
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discussed in this manuscript.

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Conflict of Interest/Funding: Nil.

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Figure captions

Fig. 1.A. Percentage of the possible high score (50 points) on the HOPE questionnaire
comparing Surgeon 1 and Surgeon 2. B. Absolute values of the HOPE score comparing
operating surgeon and non-operating surgeon (n=13 patients, where one questionnaire was
completed by the surgeon who had operated on the child).

Fig. 2.A. Percentage of the possible high score (18 points) on the PPPS questionnaire

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comparing mothers and fathers. B. Correlation analysis of the single items of the PPPS
comparing mothers (m) and fathers (f), r = correlation coefficient (Spearman)

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Fig. 3. Burden due to the operation of the child on a scale from 1-6 (1 lowest, 6 highest) as
perceived by mothers and fathers.

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Fig. 4.A. Percentage of the possible high score comparing parents (PPPS) and surgeons
(HOPE score). B. Opinions of parents and surgeons in answer to the single question ‘To what

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extent are you satisfied with the general (postoperative) appearance of the penis?’ not using a
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scoring system.
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Surgical and cosmetic result after hypospadia correction

from a parents point of view

Parents questionnaire

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patient data

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I am

o the father o the mother

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Did you attend the preoperative counseling personally (on the day before operation)?

o yes
U o no
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PPPS Score (Weber et al., JUrol 09/2008)

a penile lenght
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(0) very dissatisfied (1) dissatisfied (2) satisfied (3) very satisfied
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b position and shape of the urethral opening

(0) very dissatisfied (1) dissatisfied (2) satisfied (3) very satisfied
EP

c shape of the glans

(0) very dissatisfied (1) dissatisfied (2) satisfied (3) very satisfied

d shape of the penile skin

C

(0) very dissatisfied (1) dissatisfied (2) satisfied (3) very satisfied
AC

e penile axis (straightness upon erection)

(0) very dissatisfied (1) dissatisfied (2) satisfied (3) very satisfied

f general appearance of the penis

(0) very dissatisfied (1) dissatisfied (2) satisfied (3) very satisfied

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+1 From your point of view, have you been informed accordingly on removal of the
foresking during preoperative consultation?
o yes o no

+2 Did the operation lead to a clear amendment of the cosmesis of your sons outer
genitalia from your point of view?
o yes o no

PT
+3 A major reason for operating your son was to amend the cosmesis of his outer
genitalia. For us, it would be important to know, how you assess the success of this

RI
cosmetic correction now:
a. Will your son be satisfied with the aspect of his outer genitalia?
o yes, he will be satisfied o no, he will have problems therewith

SC
b. Do you believe, that your son may have an impaired self-confidence due to the
appearance of his ourter genitalia?
o no o yes

U
+4 For parents, having their sons operated, the operation means a considerable
AN
burden. As how much of a burden have you experienced your son’s operation
yourself?
o1 o2 o3 o4 o5 o6
M

1 = low burden, 6 = heavy burden

D

Thank you for your contribution!

TE
C EP
AC

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Surgical and cosmetic result after hypospadia correction

from a parents point of view
Surgeons questionnaire / HOPE Score

patient data

PT
RI
Date of operation: ____________

Date of inclusion: ____________

SC
Surgeon filling out the quesionnaire
❑ Osw ❑ Bec ❑ Koen ❑ Ber ❑ Hd

U
❑
Wag
AN
❑ informed consent available
M

❑ surgeon on that patient ❑ not surgeon on that patient

D

meatal position at diagnosis

❑ glandular
TE

❑ coronar
❑ penile
❑ scrotal
EP

initial deviation
❑ no erection observed
❑ 0-30° (10 points)
C

❑ 30-50° (7 points)
AC

❑ 50-70° (4 points)
❑ >70 (1 point)

❑ first operation ❑ 1. ReDo operation ❑ > 1. ReDo operation

surgical technique
❑ TIP ❑ MAGPI ❑ Matthieu ❑ Bracka I/II ❑ Thiersch-Duplay

other method:__________________

How do you judge the general appearance of the penis?

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❑ very dissatisfied ❑ dissatisfied ❑ satisfied ❑ very satisfied
HOPE Score Assessment
(Fred van der Toorn, Tom de Yong, Piet Hoebecke et al., JPUrol, 03/2013)

1. Position meatus: assess the position of the meatus? See HOPE-score reference
pictures
❑ Position 1 (10 points)

PT
❑ Position 2 (8 points)
❑ Position 3 (5 points)
❑ Position 4 (3 points)

RI
❑ Position 5 (1 point)

2. Shape meatus: what is the shape of the meatus? See HOPE-score reference

SC
pictures
❑ Normal (10 points)
❑ Slightly abnormal (7 points)
❑ Moderately abnormal (4 points)

U
❑ Severely abnormal (1 point)
AN
3. Shape glans: what is the shape of the glans? See HOPE-score reference pictures
❑ Normal (10 points)
❑ Slightly abnormal (7 points)
M

❑ Moderately abnormal (4 points)

❑ Severely abnormal (1 point)

4. Shape Skin: what is the shape of the penile skin? See HOPE-score reference
D

pictures
❑ Normal (10 points)
TE

❑ Slightly abnormal (7 points)

❑ Moderately abnormal (4 points)
❑ Severely abnormal (1 points)
EP

5.1 Torsion: is there a torsion of the penis?

❑ 0-30° (10 points)
❑ 30-50° (7 points)
C

❑ 50-70°(4 points)
AC

❑ >70 (1 points)

5.2 Curvature in penile

erection: is there a
curvature of the penis in
erection?
❑ No erection observed
❑ 0-30° (10 points)
❑ 30-50° (7 points)
❑ 50-70° (4 points)
❑ >70 (1 point)

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Thank you for your contribution!

PT
RI
U SC
AN
M
D
TE
C EP
AC

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Table 1. Chart outlining data set

Patient age at operation Mean 25.76 months, median 15 months

Number of parents/surgeons 42 (42 fathers, 42 mothers, 84 surgeons)

pairs questioned

PT
Response rate/parent pairs 29/42 (equals 58/84 PPPS questionnaires)
mailing back a usable PPPS

RI
questionnaire

Reasons for drop out Did not mail back 9 parent pairs

SC
Mailed back an unusable questionnaire 4 parent pairs
Withdrew their consent 4 parent pairs

U
Meatal localization Glandular 2 (6.9%)
Coronar 20 (68.9%)
AN
Penile 6 (20.6%)
Penoscrotal 1 (3.4%)
Number of operations for Mean 1.103 (2 operations in 3 patients, 1 operation in 26
hypospadias correction patients)
M

Hypospadias repair Tubularized incised plate 26 (89.7%)

D

technique Tubularization without incision 1 (3.4%)

Meatal advancement/glanduloplasty 2 (6.8%)
TE

PPPS, pediatric penile perception score

C EP
AC
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