The authors of the article titled “Late chordee correction after tubularized incised plate repair for proximal hypospadias: An underreported problem” published in
UroPrecision in 2024[
1], should be congratulated for presenting an important yet underreported complication of treating proximal hypospadias with techniques preserving the urethral plate (UP), essentially tubularized incised plate (TIP) repair in this report. There are several important aspects of hypospadias repair that need to be highlighted in this context.
It should be noted that the importance of objective estimation of ventral curvature (VC) during primary (and redo) hypospadias repair cannot be overemphasized. Several studies have shown that most pediatric urologists utilize unaided visual inspection (UVI) to estimate VC during hypospadias repair[
2,
3]. UVI has been shown to be unreliable in both clinical and experimental studies[
3–
5], and may lead to erroneous surgical decisions. Thus, the first and essential step in hypospadias repairs is the objective measurement of VC using goniometry, preferably with a smartphone app[
6]. Several authors reported that preservation of UP in proximal hypospadias with VC > 30° resulted in a high incidence of residual/recurrent VC during follow-up[
7,
8]. It should be noted that Snodgrass himself does not advocate TIP repair for proximal hypospadias with VC > 30°[
7]. Recent meta-analysis has shown that UP transection followed by 2-stage repairs produced consistently better results than single-stage repairs of proximal hypospadias[
9]. In addition, there are some concerning reports that the midline UP incision might cause acquired VC during follow-up after TIP repair of even distal hypospadias! Abbas et al.[
10] reported on a patient post TIP urethroplasty for distal hypospadias without chordee who developed urethral stenosis and 60° acquired curvature along the territory of the incised plate necessitating a redo surgery using a 2-stage oral mucosal graft repair. The histological analysis of the incised urethral plate revealed absence of smooth muscles, vessels and elastin fibers within the area of the incised plate which could explain the poor compliance of this segment and the development of the curvature. These reports raise serious concerns regarding the long-term fate of the incised UP in TIP repair, and I suspect that the reported complications may only represent the proverbial tip of the iceberg!
So what is the take-home message from the article[
1] and this mounting evidence about recurrent VC after hypospadias repair? Overzealous attempts to preserve and utilise the dysplastic UP to perform a single-stage correction of proximal hypospadias should be avoided, especially when the VC is > 30° after degloving. The obituary for utilization of TIP repair in proximal hypospadias should be written as soon as possible, before many more children are condemned to undergo multiple complex reoperations to correct its complications.
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