Letters to the Editor 85 pts) that are not homogeneous in numbers and age, probably the author should have compared similar groups [1,2]. In addition it is unclear who evaluated results in Snodgrass study, we think, as stated in our prospective study published in 2007 on WJU, that the results were evaluated by two pediatric surgeons not involved in the operation and unaware of the type of treatment the patients had undergone [1,2]. In conclusion, we think that prepuciolasty is important, above all for esthetic aspects of the new penis. It has to be always performed, if possible, and the indication “to do it” has to be decided by the surgeon and not only by parents. We believe that preputial anatomic observation based on experience of the surgeon is mandatory to recommend the prepucioplasty in patient with hypospadias.
407 tions after distal TIP hypospadias repair. J Pediatr Urol; 2012; Jul 30. [2] Savanelli A, Esposito C, Settimi A. A prospective randomized comparative study on the use of ventral subcutaneous flap to prevent fistulas in the Snodgrass repair for distal hypospadias. World J Urol 2007;25:641e5. [3] Wilcox D, Snodgrass W. Long-term outcome following hypospadias repair World. J Urol 2006;24:240e3.
C. Esposito) A. Savanelli A. Settimi Department of Pediatrics, Federico II University, Naples Italy Via Pansini 5, 80131 Naples, Italy E-mail address:
[email protected] (C. Esposito) )Corresponding author. Tel.: þ39 081 746 33 78; fax: þ39 081 746 33 61.
References [1] Snodgrass W, Dajusta D, Villanueva C, Bush N. Foreskin reconstruction does not increase urethroplasty or skin complica-
ª 2013 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company. http://dx.doi.org/10.1016/j.jpurol.2013.01.003
Response to Esposito et al.
The central message of our study is that preputioplasty does not increase urethroplasty complications after distal TIP hypospadias repair. Savanelli et al. agree with this finding. Our report included 85 consecutive boys whose parents desired preputioplasty, while Savanelli et al. performed foreskin reconstruction on all 130 boys enrolled in their trial of dartos flaps. None of our patients wanting reconstruction were found to have an “unsuitable” foreskin precluding it. Apparently none of their patients did either. While there may be an occasional boy with some anatomic feature that prevents foreskin reconstruction, this would seem both very unusual and also a determination that could only reliably be made intraoperatively. For these reasons we state again: the surgeon should be guided by the wishes of the parents. To be clear, we did not refer Savanelli et al. because their study did not evaluate potential differences in urethroplasty outcomes in patients with versus without preputioplasty, but rather compared a dartos flap covering the neourethra to no flap in patients who all underwent preputioplasty. As we state in our article, a randomized trial of preputioplasty vs. circumcision is not possible while providing the cosmetic results preferred by caregivers, and thus we used statistical analysis with multiple logistic
DOI of original article: http://dx.doi.org/10.1016/j.jpurol. 2013.01.014.
regression precisely to address the concerns of Savanelli et al. regarding underlying differences between patients with preputioplasty vs. circumcision. We disagree with the old adage to preserve foreskin in case it is needed for repair of complications. Fistulas can be covered by ventral dartos flaps and reoperations can be done by TIP, inlay grafting, or 2-stage oral mucosa grafts ‒ all without the need for foreskin. Again, the desire of the parents for either preputioplasty or circumcision can be followed. Finally, we believe hypospadias surgery must move past the idea that anatomic observations “based on the experience of the surgeon” should direct decision-making. Shimada et al. did not define what a “suitable foreskin” for preputioplasty is, and it is likely that various surgeons examining the same child would reach different conclusions about what is suitable or not. Scientific progress depends on our ability to objectively define indications and contraindications for operations. Our findings and those reported by Savanelli et al. do not suggest there are 5e10% of distal hypospadias cases in which preputioplasty cannot be performed because of some anatomic feature of the foreskin.
Note to author The term ‘preputioplasty’ has been corrected in the commentary and response (spelt incorrectly as ‘prepucioplasty’ in the original paper).
408 Nicol Corbin Bush) Warren T. Snodgrass University of Texas Southwestern Medical Center, Pediatric Urology, 2350 Stemmons Frwy., Suite D-4300 MC F4.04, Dallas, TX 75207, United States
Letters to the Editor E-mail address:
[email protected] (N.C. Bush) )Corresponding author. Tel.: þ1 214 456 0619; fax: þ1 214 456 2497.
ª 2013 Published by Elsevier Ltd on behalf of Journal of Pediatric Urology Company. http://dx.doi.org/10.1016/j.jpurol.2013.01.003
