Journal of Pediatric Urology (2014) 10, 783e785

LETTERS TO THE EDITOR

Re: “Snodgrass W, et al. Duration of follow- long-term follow-up is not necessary and is not cost-
up to diagnose hypospadias urethroplasty effective. The selection of which hypospadias has to be
complications.” J Pediatr Urol followed up further than 8 months is already a first bias
2014;10:208e211 that might alter the conclusion. The way this biased
follow-up is used to extrapolate the first conclusion to the
whole cohort makes the conclusion of the author
completely out of the scope of the pre-defined objectives
of the manuscript.
The manuscript of Warren Snodgrass et al. entitled “Dura-
We refer to our manuscript published earlier, which was
tion of follow-up to diagnose hypospadias urethroplasty
used as a reference and which was discussed [6].
complications” is very interesting [1]. Retrospectively
Reporting data of complications in hypospadias surgery
analyzing a prospectively maintained database of incised
is a delicate matter and comparing these data is even more
urethral plate urethroplasties, Warren Snodgrass wishes to
challenging. In our study, we did not focus on specific
prove that the majority of the complications of ure-
complications or on time to diagnosis of possible compli-
throplasties can be diagnosed within a year after surgery.
cations. We addressed the issue by a more holistic view by
This could be a really interesting finding, given the guide-
scoring the need for reintervention for any reason related
lines in hypospadias, based on expert opinions and on
to the primary repair as we believe this is more adapted for
scarce long-term follow-up studies, failed to provide us
clinical practice. We state that, although there is a
with recommendations on how long the follow-up after
discrepancy in our manuscript between time to diagnosis
hypospadias repair should be advised [2].
and time to reintervention, there is an even more impor-
However, taking a closer look at the analysis Warren
tant part of complications that is missed when reporting
Snodgrass performed, one might actually realize that the
only complications appearing within first year after surgery.
author actually wished to prove his way of reporting
In our retrospective study we identified all complica-
hypospadias complication is the ideal one. Many authors
tions which required reintervention. The decision to work
might also agree with this finding, as many studies reporting
with the date of reintervention, rather than the date of
outcome in hypospadias surgery are, just like the studies of
diagnosis of a complication, helped us to identify
Warren Snodgrass, based on short-term analysis of out-
those complications that really matter. From our data,
comes, mostly shorter than 1 year [1,3e5].
fistula was the reason for reintervention in nine, 3% of all
That could be really interesting if the author had
the patients operated on in our distal group. However, in
managed to prove this finding based on solid grounds.
total 21,3% of patients in the distal group needed rein-
However, with the data provided, one cannot come to the
tervention. Of all reinterventions (n Z 114), 52 were
conclusion claimed by the author, that long-term follow-up
fistulae which occurred between 4 and 67 months after
of hypospadias is not mandatory to detect the real
initial surgery. Limiting the follow-up to 12 months obvi-
complication rate. The author based his conclusion on a
ously does obviously not allow to diagnose all of those
short-term follow-up for most of the patients, as patients
fistulae.
were discharged after the 8-month visit if there was no
Results of hypospadias surgery are subject to complex
problem in case of distal hypospadias.
interactions, like grade, technique, experience of the
The follow-up longer than 8 months after initial repair,
surgeon, type of used material for reconstruction, etc. In
which is then considered by the author as long-term
our cohort of primary repairs an important influence of
follow-up, occurred only in some patients (proximal and
type of hypospadias on the need for reintervention was
midpenile hypospadias, distal hypospadias with compli-
observed. Selective reporting of urethral complications in
cations) and is used to extrapolate the results of the pa-
primary and reoperative cases is, no matter what might
tients with short follow-up, coming to the conclusion that
Warren Snodgrass think, certainly not a good way to
identify the real complication rate of this surgery. Selec-
tion of cases with reported urethral complication without
information on other outcomes and too short follow-up are
flaws of the retrospective study of Snodgrass et al. We
DOI of original article: http://dx.doi.org/10.1016/ tried to reduce bias by assessing all hypospadias patients
j.jpurol.2014.04.022.
784
operated in a certain period of time regardless of which
technique used for primary repair. Our study proves that
long-term follow-up with urethral and global esthetic
outcome is needed to detect the real complication rate of
hypospadias repair.
We do yet agree with Warren Snodgrass on the fact
that the majority of hypospadias patients need only one
operation for good long-term outcome and that most of the
complications are observed early. But the question of ideal
follow-up in clinical practice may be different from that in
good scientific literature. And the data provided in the
manuscript of Warren Snodgrass does not allow to reach the
conclusion claimed by the authors, that short-term follow-
up limited to 12 months, or even as in this manuscript, to 8
months in the distal group of hypospadias, is enough. We
conclude that reporting of outcomes in hypospadias surgery
remains a challenge and needs a holistic approach. A
meticulous description of the study population and design
together with long-term follow-up is mandatory to
determine the “real” complication rate, which is certainly
not provided in Warren Snodgrass manuscript. Prospective
databases with validated outcome measures are the only
way to finally sort the issue.
References
[1] Snodgrass W, Villanueva C, Bush NC. Duration of follow-up to
diagnose hypospadias urethroplasty complications. J Pediatr
Urol 2014;10:208e11.
[2] Tekgül S, Riedmiller H, Dogan HS, Hoebeke P, Kocvara R,
Nijman R, et al. Guidelines on pediatric urology. EAU guide-
lines [Internet]. March 2013. update.
[3] Snodgrass W, Macedo A, Hoebeke P, Mouriquand PD. Hypo-
spadias dilemmas: a round table. J Pediatr Urol 2011;7:
145e57.
[4] Bush NC, Holzer M, Zhang S, Snodgrass W. Age does not impact
risk for urethroplasty complications after tubularized incised
plate repair of hypospadias in prepubertal boys. J Pediatr Urol
2013;9:252e6.
[5] Snodgrass W, Koyle M, Manzoni G, Hurwitz R, Caldamone A,
Ehrlich R. Tubularized incised plate hypospadias repair for
proximal hypospadias. J Urol 1998;159:2129e31.
[6] Spinoit AF, Poelaert F, Groen LA, Van Laecke E, Hoebeke P.
Hypospadias repair at a tertiary care center: long-term fol-
lowup is mandatory to determine the real complication rate. J
Urol 2013;189:2276e81.
Anne-Françoise Spinoit*
Filip Poelaert
Piet Hoebeke
Department of Urology, Ghent University Hospital,
De Pintelaan 185, 9000 Gent, Belgium
*Corresponding author. Tel.: þ32 9 3322276;
fax: þ32 9 3323889.
E-mail address: afspinoit@hotmail.com (A.-F. Spinoit)
Letters to the Editor
ª 2014 Journal of Pediatric Urology Company. Published by
Elsevier Ltd. All rights reserved.
http://dx.doi.org/10.1016/j.jpurol.2014.04.019
Response to “Re: Snodgrass W,
et al. Duration of follow-up to
diagnose hypospadias urethroplasty
complications. J Pediatr Urol
2014;10:783e784”
Potential outcomes from hypospadias repair include
urethroplasty complications (fistula, glans dehiscence,
meatal stenosis, urethral stricture, diverticulum), urinary
function (spraying, deflected stream, uroflow rate), sexual
function (straightness of erection, ejaculation), and
cosmetic appearance. While there is merit in determining
all these, with the majority of operations done in pre-
toilet-trained boys, it is most common to assess various
techniques by comparing urethroplasty complications
(UCs). However, few studies specifically state when such
UCs were diagnosed, and so the duration of follow-up to
encounter the majority of them remains ill-defined.
Although many authors write that follow-up should
continue into puberty after childhood repair, and some
describe such assessments as taking place for approxi-
mately a year or so after surgery, then at toilet-training,
and again during puberty; there are no publications
reporting the findings at each of these intervals and the
percentage of patients that complied with the protocol. It
is unlikely that many patients, even those within national
health-care systems, will continue long-term follow up
many years postoperatively, especially if they either
perceive no complications, or do not desire additional
surgery if they are aware of one.
So a standard is needed for reporting these UCs, real-
izing that more complications might occur in study patients
in the future. We acknowledged in the Discussion the
various criticisms expressed in this letter to the editor. But
while the writer is correct that our conclusions are poten-
tially biased by our methods, he is not correct to state our
goal was to validate these methods. Rather, this study was
motivated by our analysis of patients not returning for their
recommended follow-up to determine the minimum time to
diagnose most UCs.
The writer similarly used UCs as a major outcomes
measure in his article (reference 5 in the article), adding
only cosmetic appearance and “other” as reasons for
reoperations. Overall, reintervention was done in 24% of
their patients, 47% of which occurred within the first year.
Unfortunately, the authors did not state when most of their
UCs were diagnosed, but instead only provided the range of
time. While all hypospadiologists know an occasional
DOI of original article: http://dx.doi.org/10.1016/
j.jpurol.2014.04.019.