Journal of Pediatric Urology (2020) 16, 306.e1e306.
e8
a
Department of Pediatric
Surgery, Skåne University
Hospital, 221 85, Lund, Sweden
b
Department of Clinical
Sciences, Pediatrics, Lund
University, Lund, Sweden
* Correspondence to: Hans
Winberg, MD Department of
Pediatric Surgery, Skåne
University Hospital, 221 85,
Lund, Sweden. Tel. No:
þ46708221202.
winberghans@gmail.com (H.
Winberg)
magnus.anderberg@med.lu.
se (M. Anderberg)
einar.arnbjornsson@telia.
com (E. Arnbjörnsson)
pernilla.stenstrom@med.lu.
se (P. Stenström)
Keywords
Hypospadias; Reconstruction;
Outcome; Complications; Uri-
nary flow measurements;
Fistula
Received 27 November 2019
Accepted 7 March 2020
Available online 29 March 2020
https://doi.org/10.1016/j.jpurol.2020.03.004
1477-5131/ª 2020 Journal of Pediatric Urology Company. Published by Elsevier Ltd. All rights reserved.
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Urinary flow measurement in
hypospadias correlated to surgical
procedure and risk of development of
urethra-cutaneous fistula
Hans Winberg a,b,*, Magnus Anderberg a,b, Einar Arnbjörnsson a,b,
Pernilla Stenström a,b
Summary
Aim
To explore the correlation between fistula development and
urinary flow measurements after hypospadias repair with
emphasis on patients with urethrocutaneous fistula com-
plications and to identify risk factors for fistula
development.
Methods
Urinary flow was examined in boys operated on for hypo-
spadias. Outcome of maximum urinary flow (ml/s) (Qmax),
voided volume for age (ml) (Volume), and pathological flow
pattern (n) (Curve) was compared between the Byars,
Mathieu, and Tubularized Incised Plate (TIP) surgical repair
methods and between the groups of those who had and had
not developed a fistula. Logistic regression analysis was
performed for age at operation, genetics, comorbidity, or
urinary flow measurements regarding the development of
urethrocutaneous fistula.
Results
Seventy-three boys underwent hypospadias repair. Overall,
the urinary flow measurements differed significantly be-
tween the three reconstructive methods, being favorable
for the Mathieu procedure regarding Qmax (p < 0.01), vol-
ume (p Z 0.04), and frequency of pathological voiding
curve (p < 0.01; Table). The frequency of urethrocutaneous
fistula was 18% (13/73) and did not differ significantly be-
tween the three different reconstructive surgery methods
(Byar 33%, Mathieu 32%, and TIP 12%; p Z 0.22). Urinary
flow measurements did not differ between patients with
Summary Table Urinary flow measurements: Qmax, volume and the curve formation correlated
to the technique of operation
Parameters Byar
Patients, N Z 73 3 19
Qmax Median (range) ml/s 6 (5e7)
Volume Median (range) ml 26 (19e32)
Curve-Bell form 3 (100%)
-Plateau-shaped*** 0 0
*
KruskaleWallis Test.
**
The Fisher exact probability test for two-rows by three-column contingency table, the Freeman-
Halton extension.
***
Pathological suggesting obstruction.
and without fistula complications regarding Qmax 10 ml/s
(4e16) vs. 8 ml/s (2e18), voided volume 74 ml (35e171) vs.
71 ml (9e270), or abnormal urinary flow pattern (23% vs.
30%). On logistic regression analysis, age at operation, ge-
netics, comorbidity, and urinary flow measurement pa-
rameters did not turn out to be independent risk factors for
development of urethrocutaneous fistula after hypospadias
repair.
Discussions
The study demonstrated significant differences between
the urinary flow measurement results between the three
different repair methods, favoring the Mathieu procedure.
A low Qmax was a common postoperative finding. Urinary
flow measurements did not differ between boys developing
fistula and those who did not. No risk factors for fistula
development were identified. The study did not support
that it would be possible, at an early postoperative stage,
to identify those with an upcoming postoperative fistula
neither with urinary flow measurements nor through risk
factors. No similar reports have studied the possibility of
using postoperative urinary flow measurements to deter-
mine patients at risk of fistula development after hypo-
spadias repair.
Conclusions
Urinary flow measurements were favorable after hypospa-
dias reconstruction with Mathieu compared with Byars and
TIP. Furthermore, urinary flow measurements did not differ
between reconstructed with and without a fistula compli-
cation. No risk factor for fistula development was
identified.
Mathieu TIP P value
51
11 (8e15) 7 (2e18) <0.01*
95 (35e380) 71 (0e257) 0.04*
18 (95%) 29 (57%) <0.01**
21 (41%)
Urinary flow measurement in hypospadias
Introduction
Hypospadias repair is hampered with postoperative com-
plications, including the development of urethrocutaneous
fistula [1e3]. Local postoperative infections are reported to
cause urethrocutaneous fistula [4] and increased urethral
pressure due to anastomotic narrowing, stricture related to
suture material, and selected surgical methods are high-
lighted in the scientific discussion [5].
No reports have investigated any early signs that may
indicate a risk for fistula development, such as obstructive
flow. Our hypothesis was that very high flow pressure
proximal to the urethral anastomosis due to obstruction in
the reconstructed area may lead to development of a fis-
tula. Knowledge regarding this would be important in the
postoperative treatment after hypospadias repair, if uri-
nary diversion or early dilatation of urethral stricture would
help to avoid fistula development.
The aim of the present study was to correlate the find-
ings of routine postoperative urinary flow measurements to
the three different surgical methods utilized, with special
emphasis on outcome after hypospadias repair regarding
fistula development. We are not aware of any similar report
in the literature.
Material and methods
Settings and patients
This study was based on a routine follow-up in conjunction
with a local hypospadias register and database. Patients
were identified from the register, and data on patient
characteristics, surgical procedures, and complications
were retrospectively extracted from the prospectively
collected database. Outcomes of the postoperative urinary
flow examinations were retrospectively collected from the
medical records.
All patients received treatment at a tertiary center of
pediatric surgery, which performs approximately 50% of
hypospadias procedures in a region comprising approxi-
mately 1.8 million residents and 22,000 live births every
year. The study group included all boys who underwent
primary surgery for urethral reconstruction for hypospadias
grade 1e3.
Hypospadias were classified into three different types:
glanular (1st degree), penile (2nd degree), and penoscrotal
(3rd degree) [3,6].
Surgical procedures
Mathieu repair
During the Mathieu procedure [7], a meatal-based skin flap
is turned 180 and sutured into the incision on both sides of
the glanular groove and along the tip. Curvature is cor-
rected when present. The glanular wings are closed in the
midline thereby making a tunnel for the distal neourethra.
The skin on the penile shaft is mobilized and closed over
the “flap gap.” A suprapubic catheter is used for urinary
diversion.
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306.e2
Tubularized Incised Plate (TIP) repair
During TIP repair [8e10], a U-shaped skin incision is made
along the edges of the urethral plate, and the penis is
degloved. A midline incision is made to widen the urethral
plate along its length, which is then tubularized over a
stent. A pedicle of subcutaneous tissue is dissected from
the ventral or dorsal penile skin and used to cover the
neourethra. Finally, a midline closure of the glanular wings,
mucosal collar, and ventral penile skin is performed.
Byars technique
The Byars technique [11] is a 2-stage process that begins
with a straightening procedure. A circumferential incision is
made proximal to the coronal sulcus, and the curvature is
corrected with penile degloving. The artificial erection test
is used to confirm penile straightening and full removal of
tension-creating structures. The glans is either divided
deeply in the midline to the tip or, if the mucosal groove is
deep, it is preserved, and incisions are made lateral to the
groove on each side. The dorsal foreskin is unfolded care-
fully and divided in the midline. The most distal segment of
the foreskin is rotated into the glanular cleft and sutured to
the mucosa of the glans. A midline closure is performed,
with the midline sutures catching a small portion of Buck’s
fascia. Using an 8 FR Silastic Foley catheter, the bladder is
drained for approximately 5e7 days.
The second stage is performed 6e12 months later when
the tissues have sufficiently softened, and healing is com-
plete. The previously transferred preputial skin is used for
glans and urethral reconstruction. A 16 mm diameter strip
is measured, which extends to the tip of the glans, and
tubularized with a running subcuticular stitch to the tip of
the glans. The lateral skin edges are mobilized, and the
remaining tissue is closed over the repair in at least two
layers. Next, a strip of skin (3e5 mm wide) is de-
epithelialized on one side to provide a raw surface of the
deep dermis. The medial edge of the shaved flap is brought
across the buried urethroplasty and sutured to the fascial
tissue beneath the other flap.
Fistula
A fistula was defined as an opening between the urethra
and the skin of the penis, allowing urine to pass here.
Prophylactic antibiotics
Patients were routinely administered intravenous prophy-
lactic trimethoprim-sulfamethoxazole (Eusaprim ).
Surgeons and care
The senior hypospadias surgeon at the hospital, or a sur-
geon trained by him, performed all the reconstructions and
was responsible for the preoperative workup, postoperative
follow-up, and registration. The bandage and the catheter,
whether suprapubic, Foley, or a dripping stent, was kept in
place for a week and removed at our outpatient clinic.
Fistulas were repaired by the same surgeon who performed
the primary reconstruction.
306.e3
Urinary flow measurements
According to the standard method, urinary flow measure-
ments and maximum urinary flow (Qmax) (ml/s), voided
volume (ml), and urinary flow curve pattern were
measured. The urinary flow curve pattern was considered
normal if the curve was bell-shaped, or pathological if it
was plateau shaped.
Urinary flow was analyzed, and the development of fis-
tula was evaluated after each primary surgical procedure.
Moreover, the urinary flow was compared between the boys
who developed and did not develop postoperative fistula.
Statistical considerations
Previous data indicate that the probability of exposure
among controls is 0.2. If the true probability of exposure
among cases is 0.8, we needed to study seven patients
(developing fistula) and 35 control patients (without fistula)
to be able to reject the null hypothesis that the exposure
rates are equal with probability (power) 0.8 for both cases
and controls. The Type I probability error associated with
this null hypothesis test is 0.05. The null hypothesis was
evaluated using a continuity-corrected chi-square statistic
or the Fisher exact test [12].
Multivariable regression analysis was performed to
investigate possible risk factors for postoperative fistula,
with fistula as the outcome, firstly, age at operation, ge-
netics, and comorbidity, and secondly, age at operation and
urinary flow measurement parameters as independent
variables, respectively. A P value of <0.05 was considered
significant. Statistical analyses were approved by a medical
statistician and performed using IBM SPSS Statistics, version
24.0 (IBM Corp., Armonk, NY) and Excel 2016 (Microsoft
Corporation).
Ethical considerations
This study was conducted according to the revised Decla-
ration of Helsinki adopted in 1964 and the Good Clinical
Practice guidelines. The study was endorsed by the
Regional Ethical Review Board (registration number 2010/
49). The data were coded and de-identified. The children
included in the study were registered according to the
regional demands on quality registry, number
01481271007173.
The study protocol was designed to conform to the leg-
islative documentation required by the country of origin.
The data were anonymized before calculations were made
and presented in such a manner that made it impossible to
identify or link to any specific individual. Therefore,
informed consent from the patients’ parents or guardians
was not necessary to conduct this study. It was not possible
to go back and trace or identify any of the participants.
Because these were retrospective data from a prospec-
tively collected database, the treatment plan of each pa-
tient was not altered. All the described evaluations,
treatments, and procedures followed the standard of care
and were performed at a tertiary center for pediatric sur-
gery. No protocols requiring informed consent or institu-
tional review board approval were utilized. The risk of
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H. Winberg et al.
physically, socially, or psychologically harming the patients
in the present study was nonexistent.
Results
For the boys who underwent hypospadias repair, data
regarding degree of hypospadias, surgical procedure, fistula
development, and other congenital urogenital anomalies
are summarized in Table 1 and were not significantly
different between the three different hypospadias repair
methods. Overall, 11% (8/73) of the boys had a genetic
susceptibility for hypospadias, without any correlation to
the development of postoperative fistula.
The urinary flow measurement results significantly
differed between the three reconstructive methods and
were favorable for the Mathieu procedure in the following
items: flow, volume, and curve pattern (Table 2). A sub-
group analyses limited to penile and distal hypospadias only
as well as to Mathieu and TIP only disclosed the same re-
sults with the exception that there was no difference be-
tween Mathieu and TIP regarding the voided volume (Tables
2 and 3). Furthermore, a separate subgroup analysis of the
different forms of hypospadias was conducted. No signifi-
cant difference was observed between the three different
grades of hypospadias or the types of repair and the fre-
quency of fistula development (Table 3).
The age at surgical reconstruction was 4 (1e6) and 4
(1e8) years for those with and without fistulas, respectively
(p Z 0.21). The duration of follow-up time between surgery
and urinary flow examinations was 2 months (range: 13
dayse31 months) and 1 (1e7) months, respectively
(p Z 0.76; Supplementary table). The huge spread in
duration was caused by the patients visiting for planned
follow-ups as well as when they had symptoms. The time
for development of fistulas after surgery was median 2
(0e11) months. Five of the 13 boys with fistula had already
developed a postoperative urinary fistula at the time of
urinary flow measurement and eight developed it later.
The urinary flow measurement results did not signifi-
cantly differ in boys developing a fistula after hypospadias
repair versus those who did not (Table 3). The result did not
change when excluding those who had a fistula for the first
postoperative urinary flow measurement. In a subgroup
analyses, the flow results from the three Byar flaps repairs
were excluded. In all these, the voided volume was low.
Excluding the Byar repair did not change the non-significant
findings of the study (Tables 2 and 3). The flow measure-
ments comparing boys with hypospadias grade 1 and 2 did
not disclose any significant difference (Table 3).
Logistic regression analysis did not identify any risk
factor for complications after hypospadias repair in our
study. Especially logistic regression analysis did not identify
the age at operation, genetics, comorbidity, or urinary flow
measurement parameters to be independent risk factors for
the development of fistula after hypospadias repair (Table
4).
Discussion
The results of the present study demonstrate significant
differences between the urinary flow measurement results
Urinary flow measurement in hypospadias 306.e4

Table 1 Data on 73 boys who underwent hypospadias surgery regarding degree, urethrocutaneous fistula other congenital
urogenital malformations, and prophylactic antibiotics.
Total Byar Mathieu TIP P value
N (%) 73 3 (4%) 19 (26%) 51 (70%)
Age at operation, years (range) 4 (1e8) 4 (1e4) 4 (1e6) 4 (1e8) 0.79*
Grade 1 (distal) 20 (27%) 0 4 16 0.89**
Grade 2 (shaft) 50 (68%) 1 15 34 0.78**
Grade 3 (proximal) 3 (4%) 2 0 1 NA****
Urethrocutaneous fistula 13 (18%) 1 (33%) 6 (32%) 6 (12%) 0.22**
Other congenital malformation*** 8 (11%) 0 2 (11%) 6 (12%) 1.00**
Antibiotics 61 (89%) 3 (100%) 14 (74%) 44 (86%) 0.95**
N: number of patients; values are presented as the absolute number and percentage of patients; n (%).
*
ManneWhitney U-Test (two-tailed).
**
The Fisher exact probability test for two-rows by three-column contingency table, the Freeman-Halton extension.
***
The other congenital urogenital malformations (n) included: inguinal hernia (6), undescended testis (1), pelviseureteral junction
(PUJ) obstruction (1), renal agenesis (1), vesicoureteral reflux (VUR) (1), persistent Müllerian structures in disorders of sexual differ-
entiation (DSD) conditions (1) as well as renal dysplasia (1).
****
NA: not applicable due to small number of patients.

between the three different repair methods, favoring the
Mathieu procedure. Urinary flow measurements did not
differ between boys developing fistula and those who did
not. Furthermore, no risk factors for fistula development
were identified. The study did not support that it would be
possible, at an early postoperative stage, to identify those
with an upcoming postoperative fistula neither with urinary
flow measurements nor through risk factors. As far as we
are aware, no similar reports have studied the possibility of
using postoperative urinary flow measurements to deter-
mine patients at risk of fistula development after hypo-
spadias repair.
The subgroup analyses comparing Mathieu and TIP
revealed significant difference in Qmax without significant
difference in the voided volume. It is not surprising that the
Mathieu repairs had better flow rates than the TIP repairs
considering the differences in the technique of the opera-
tive intervention. The importance of this finding as one of
the major conclusions is hampered by the lack of significant
correlation of flow rates, type of repair, and the incidence
of fistula. However, in patients where it is of importance to
avoid obstruction, to protect the upper urinary tract, the
Mathieu repair of the hypospadias may be a good choice.
There are differences in uroflow measurements after
different surgical methods of hypospadias repair as shown
in our study. These questions have been examined in pre-
vious studies collecting similar data [13e17].
After hypospadias surgery, urinary flow rates were
significantly lower than age-matched controls at long-term
follow-up [13] This low flow rate could be an intrinsic
feature of the hypospadias urethra or a consequence of the
surgical technique leaving a scar in and around the urethra
[14,17]. Urinary flow measurement was used to evaluate
the progression of uroflowmetry parameters after different
hypospadias repair techniques and showed that the choice
of surgical technique for hypospadias repair had impact on
the improvement of Qmax values. TIP improved 36 months
postoperatively [14]. Concerns have been raised on the

Table 2 Urinary flow measurements: Q max, volume and the curve formation correlated to the technique of operation.
Parameters Byar Mathieu TIP P value
Patients N Z 73 3 19 51
Qmax Median (range) ml/s 6 (5e7) 11 (8e15) 7 (2e18) <0.01*
Subgroup analyze Mathieu compared to TIP <0.01**
Volume Median (range) ml 26 (19e32) 95 (35e380) 71 (0e257) 0.04*
Subgroup analyze Mathieu compared to TIP 0.35**
Curve <0.01***
Bell form 3 (100%) 18 (95%) 29 (57%)
Plateau-shaped**** 0 0 21 (41%)
Information missing 1 1
Subgroup analyze Mathieu compared to TIP <0.01***
*
KruskaleWallis test.
**
ManneWhitney U-test, two-tailed.
***
The Fisher exact probability test for two-rows by three-column contingency table, the Freeman-Halton extension.
****
Pathological suggesting obstruction.

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306.e5 H. Winberg et al.

Table 3 Urinary flow rate and flow pattern at the first outpatients visit after hypospadias reconstruction.
Postoperative uroflow parameters With fistula Total n Z 13 Without fistula Total n Z 60 P value
Mathieu n Z 6 TIP n Z 6***** Mathieu n Z 13 TIP n Z 44*****
Q max (ml/s), mean (range) 10 (4e16) 8 (2e18) 0.37*
Mathieu 11 (8e13) 10 (8e15) 0.66*
TIP 6 (4e16) 7 (2e18) 0.80*
Voided volume (ml), mean (range) 74 (35e171) 71 (9e256) 0.83*
Mathieu 65 (35e171) 102 (56e256) 0.27*
TIP 122 (24e257) 70 (9e240) 0.32*
Urinary flow pattern:
Bell-shaped (%)*** 9 (69%) 41 (68%) 0.45**
- Mathieu/TIP***** 5/3 13/25
Plateau-shaped**** 3 (23%) 18 (30%)
- Mathieu/TIP***** 0/3 18/0
Information missing in: 1 (8%) 1 (2%)
Hypospadias
Grade 1 2 18
Grade 2 10 39
Grade 3 1 3 0.49**
*
ManneWhitney U-test (two-tailed).
**
Fisher’s exact test (two-tailed). The Freeman-Halton extension of the Fisher exact probability test for a two-rows by three-columns
contingency table.
***
Normal.
****
Pathological suggesting obstruction.
*****
Four boys excluded in the subgroup analyses due to Byar repair (3) and one Grade 3 hypospadias.
******
Flow measurements comparing boys with hypospadias grade 1 and 2 did not disclose any significant difference. Qmax, ml/sec, mean
(range) for Grade 1 was 8 (4e18) vs 9 (2e15) for Grade 2, p Z 0.48. Volume, ml, mean (range) for Grade 1 was 74 (12e257) vs 68
(23e256) for Grade 2 p Z 0.22.

long-term functionality of the reconstructed neourethra
using the TIP urethroplasty. Results of a study suggest that
the obstructive urinary flow pattern observed at early
stages in patients is possibly an intrinsic feature associated
with malformation and less of a consequence of the surgical
technique [16].
As per the findings of the study, we were unable to
correlate uroflow measurements as a predictor of fistula
development. In addition, there was no association of an
obstructive flow pattern in those who had developed a fis-
tula. However, there was an increased incidence of a
plateau pattern following a TIP procedure versus a Mathieu
repair. This increased incidence of plateau pattern did not
have any relation to an increased incidence of any other
negative clinical outcome in our small group of patients.
Reports on the use and benefit of urinary flow mea-
surements in the postoperative course of hypospadias
repair are contradictory. Some authors have suggested that
the quality of micturition should be assessed subjectively,
and when possible, confirmed objectively with uro-
flowmetry [18] but without providing suggestions on how to
interpret or implement the findings. Other authors have
reported that early uroflowmetry appears to be unnec-
essary, as the voiding history is just as effective in alerting
to the suspicion of a urethral stricture after TIP repair.
Furthermore, they reported a spontaneous normalization of
urinary flow in boys after TIP repair [19]. In another study,
authors reported a spontaneous significant improvement in
urinary flow 7 years after TIP repair, although many boys
still had a Qmax in the low normal or obstructive range [20].
In a report on follow-up data following the TIP procedure,
obstructive flow patterns spontaneously resolved [20]. This
finding is supported by those of the present study. Due to
the inconsistent reports, with the aim of improving pa-
tients’ circumstances and reaching a deeper understanding
of the postoperative course, at our department, we regu-
larly follow the postoperative status with urinary flow
measurements after hypospadias repair.
For the main outcome measure, the parameters Qmax
(ml/s) and voided volume (ml) were chosen to disclose any
abnormal urinary flow pattern because these measure-
ments are the most utilized and easily collected parame-
ters from a routine urinary flowmetry. Objective criteria
used to define obstruction on uroflowmetry are inconsis-
tently used in the literature but for defining obstruction,
presence of a plateau pattern is the most used sign
[21e29]. Furthermore, we defined obstruction as the
presence of plateau urinary flow pattern; according to this
definition, 41% boys operated with TIP had obstructive flow.
Similar obstructive urinary flow pattern has been observed
in 50% asymptomatic boys after TIP surgery [25]. According
to another urinary flow curve pattern study plateau-shaped
curves were present in overall 31% boys with hypospadias
after reconstruction, whereas all boys without hypospadias
showed normal bell-shaped flow curves [26].
The outcome of urinary flowmetry in our study had a
broad range (Table 2). This might be due to factors influ-
encing the measurements such as the urinary bladder vol-
ume, compliance, or other types of voiding disorders, not
yet diagnosed at the time of the study. Results from one
study suggest that the obstructive urinary flow pattern
observed at early stages in patients is possibly an intrinsic

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Urinary flow measurement in hypospadias
Table 4 Results of logistic regression analysis of possible
risk factors for urethral cutaneous fistulae postoperatively
after hypospadias surgery correlating the fistula to the 73
boys’ age at operation, heredity, comorbidity, and the uri-
nary flow measurements parameters.
Urethral cutaneous fistulae P Odds 95% C.I.
versus the following value ratio
parameters:
Age at operation, months 0.92 0.04 0.08e0.07
Heredity 0.98 0.11 0.22e0.21
Comorbidity 0.22 0.10 0.32e0.08
Qmax, ml 0.88 0.02 0.04e0.05
Curve 0.74 0.14 0.34e0.24
Volume, ml 0.41 0.001 0.001
e0.002
feature associated with malformation and may be less of a
consequence of the surgical technique [17]. Furthermore,
the authors noted that at 10-year follow-up, there was no
difference in Qmax between different methods of repair,
where Mathieu and TIP were included [17].
Uroflow measurements vary in boys out of diapers
without hypospadias during the first years of life [14]. Upon
comparing those values in healthy individuals with what we
found in our boys’ post hypospadias repair, the Qmax values
were found to be low. A study reported abnormal uroflow
findings after hypospadias repair in approximately two
thirds of cases and suggested that a follow-up of the urinary
flow pattern is necessary to avoid the development of silent
strictures or unnecessary intervention [14]. The low Qmax
values increase with time. In the boys in our cohort and in
whom a 2nd or 3rd uroflow study were performed, the low
Qmax values increase with time.
A systematic review of publications relating to the re-
sults of urinary flow studies after hypospadias repair dis-
closed that in most of the hypospadias patients an
influenced curve was seen, with maximum flows as low as at
the 5th percentile of the normal population [17]. A long-
term evolution of urinary function after one stage primary
hypospadias repairs the functional urinary outcomes after
surgery were compared with normal patients using nomo-
gram and between procedures. The results suggest that the
obstructive urinary flow pattern observed in patients early
on is a frequent finding after proximal hypospadias surgery.
However, because of the remarkable improvement
observed at puberty, a watchful waiting approach is pro-
posed to avoid unnecessary intervention [15].
It is important to be aware of the findings that low Qmax
is a common postoperative finding in hypospadias so that
urologists do not embark upon on an escalation of optical
urethrotomy after a hypospadias repair. The usual cited
lower cut off for normal Qmax of 15 cc/sec suggest that
lower values do not necessarily indicate obstruction in boys
without hypospadias being evaluated for lower urinary tract
symptoms.
Most surgeons generally perform primary hypospadias
repairs in those aged between 6 and 12 months of age.
Because these infants are almost never toilet-trained at the
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306.e6
time of their primary hypospadias repair, uroflow testing
cannot be performed in the immediate postoperative
period, when hypospadias complications such as fistula,
generally occur. The cohort examined in our study was
older at the time of their hypospadias repair with a median
age of 4 years. All the patients were toilet-trained at the
time of the uroflow testing, which could be performed in
the immediate postoperative period. Despite that, we must
acknowledge that five of the 13 boys with fistula had
already developed a postoperative urinary fistula at the
time of the first urinary flow measurement, and eight
developed it later. Therefore, even in these older patients
than in the typical cohort of hypospadias patients, we were
unable to obtain uroflow measurements before the fistula
developed, in all the boys. It would indeed be quite rare to
be able to collect uroflow data on a primary hypospadias
repair patient before development of a fistula or another
complication. However, the uroflowmetry technique
commonly used today could not be practically utilized in
the younger patients undergoing hypospadias repair. Thus,
this study has limited applicability and external validity in
younger boys. Because we have changed our policy to
perform hypospadias repair in boys aged 6e18 months and
because urinary flow measurement is preferably conducted
in potty-trained boys, we foresee difficulties in completing
flow measurements in the youngest and that age-
adjustments for examinations will be needed.
The strength of this study is that noncompliance due to
socioeconomic factors is unlikely as health care is free in
the region. Furthermore, the surgical interventions were all
performed by two pediatric surgeons. Urinary flow mea-
surements were performed by the same team of nurses in
the outpatient department. The main limitation of the
study is that it is a retrospective collection of data from a
prospectively gathered database, and the small number of
boys included. The technique used for the hypospadias
reconstruction was at the surgeon’s discretion and could
have influenced the outcome regarding risk factors. The
group of patients with fistulas was heterogenous, including
both patients with present fistulas and patients who later
developed a fistula.
The main weakness of our study is the small number of
patients that weakens the ability to come to any conclusion
regarding this analysis. Furthermore, the study includes a
heterogenous group of hypospadias patients with wide
range of hypospadias severity, wide range of ages, and
three different surgical approaches to repair. The uroflow
data were scheduled to be collected at the time for the first
postoperative control. In fact, some urinary flow mea-
surements were conducted later at a broad range of time-
points after the surgery. The outliers in the cohort influence
the attempts to use that data to make conclusions about
risk of complications and to compare different surgical
techniques.
The study did not support the hypothesis that urinary
flow measurements can be used to identify boys who run a
risk for fistula development after hypospadias repair. To
study the topic with sharper precision, we will need to
examine urinary flow early during the postoperative period
for early disclosure of any finding, suggesting a risk for the
development of a fistula.
306.e7
Conclusion
We show that urinary flow patterns significantly differ be-
tween reconstructive methods for hypospadias, favoring
the Mathieu procedure. A low Qmax was a common post-
operative finding. Our results do not support the hypothesis
that it is possible to use urinary flow measurements to
detect or explain postoperative fistula after hypospadias
repair.
Collection of information about postoperative urinary
flow measurements before fistula development is of inter-
est to understand the nature of the fistula development and
explore ways to avoid the complications. Because hypo-
spadias reconstructions nowadays are preferably per-
formed in very young boys, the assessment of urinary flow
must be age-adjusted.
Conflicts of interest
All authors have no conflict of interest to disclose.
Funding
None.
Ethical approval
This study was conducted according to the revised Decla-
ration of Helsinki adopted in 1964 and the Good Clinical
Practice guidelines. The study was endorsed by the
Regional Ethical Review Board (registration number 2010/
49). The data were coded and de-identified. The children
included in the study were registered according to the
regional demands on quality registry, number
01481271007173.
Acknowledgement
The authors are grateful to Håkan Lövkvist, biostatistician
at the Competence Center for Clinical Research, Skåne
University Hospital, Lund, Sweden, for statistical advice.
The authors would like to thank Enago (www.enago.
com) for the English language review.
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Time to Qmax (s) duration of time from the beginning of
voiding to maximum urinary flow
Qave (ml/s) average flow rate
PVR (ml) post-void residual urinary bladder volume

Qmax (ml/s) maximum flow rate Appendix A. Supplementary data

Voided volume (ml) volume of urine delivered during
the measurement Supplementary data to this article can be found online at
Voiding time (s) duration of the voiding procedure https://doi.org/10.1016/j.jpurol.2020.03.004.

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