Reply to Letter to the Editor by Snodgrass et al. Re "Plate Objective Scoring Tool (POST) in distal hypospadias: Correlation with POST-repair complications

Abstract

Despite the popularity of TIP correction for distal hypospadias, certain publications have raised concerns about the accuracy of statements regarding its low complication rate [1]. Even skilled surgeons have observed a significant reoperation rate of 22.2% in recent big series of 450 cases when using TIP repair for distal hypospadias [1]. This is similar to the current study where we found a 25% complication rate when using TIP repair in unfavorable urethral plates [2]. It is worth mentioning that all fistulas encountered in our series were clearly secondary to distal meatal stenosis that was captured as a primary outcome. A prevalent problem in existing hypospadiology literature is the lack of a systematic and objective severity classification instrument. The classification of meatal position in hypospadias cases does not accurately represent the severity of the phenotypic abnormalities and is prone to substantial disagreement among observers. Midpenile hypospadias in Browne 1938 or Duckett 1996 grading systems can be clustered together with coronal type in Avellan 1975, Schafer 1950 and classified as distal type by Hadidi 2004. Therefore, we developed the urethral defect ratio-based objective Hypospadias categorization system to provide a more exact, reproducible, and embryologically enforced approach [3]. Furthermore, geographical and racial variances affected by genetic factors impact the phenotypic traits of Hypospadias [4], making a "typical patient population" non-existent. These facts account for the variations in the "coronal" type across various study reports. Our study did not follow a retrospective epidemiological approach to achieve a "normal distribution." Instead, it required participants to provide opt-in consent for genital organ photography, which clearly impacted the overall representation of the cohort.