Commentary to "Hypospadias: Are we as good as we think when we correct proximal hypospadias?"

The authors should be congratulated for bringing to the spotlight something aboutwhich most experienced surgeons are discreet. The manuscript openly discusses the bad results of proximal hypospadias surgery. When the alarm is raised by one of the most experienced institutions in hypospadias surgery, a thorough look at practice and knowledge is needed. The definition of proximal hypospadias is far from being clear, and heterogeneity in reporting the initial description is one of the main factors for underestimation of bad results on posterior hypospadias surgery. Multifactorial perioperative factors may influence the outcome in proximal hypospadias. Most interventions are based on weak evidence, and their influence on the outcomes of repair is ill-defined [1]. The authors reviewed many suggestions and hypotheses explaining why correction of proximal hypospadias is more difficult than that of distal. I was eager to know more about the inherited factors of the tissues that may aggravate the prognosis of proximal hypospadias. However, the authors limited their explanation on the physical factors (length and diameter of the tube to construct). We have to admit that the challenge in hypospadias surgery is not only to obtain an acceptable urine flow but also to get a functional size of the penis as well as the absence of significant curvature at puberty. We have been surprised by our own results of adolescents operated in childhood for proximal hypospadias. The majority (74%) had impaired testicular function requiring testosterone treatment for the initial or secondary induction of puberty. Most of them had a significantly short penis (-2DS) [2]. Persistent significant penile curvature is one of the most disappointing results of hypospadias surgery. The authors have reported honestly their unpublished data on the high frequency of redo hypospadias for persistent chordee, even if the surgery was done at their expert center.