Hypospadias is a congenital malformation in which surgical correction is indicated in most cases. Postoperative patient satisfaction is important because of its influence on the child's psychological development.
To evaluate patient satisfaction with surgical outcome after hypospadias correction, comparison with physician satisfaction, and the influence of patient and treatment characteristics on satisfaction.
Design, setting, and participants
Seventy-four patients who had hypospadias surgery between 1996 and 2010 in Medical Centre Leeuwarden participated in the study.
Patient/parent and physician satisfaction scores were measured using a standardised hypospadias satisfaction questionnaire (maximum score 32), and clinical outcome using the Hypospadias Objective Scoring Evaluation (HOSE; maximum score 16). Patient and treatment characteristics recorded were: preoperative meatal location, preoperative chordee, number of planned surgeries, reconstructive type and timing, patient age during the study, complications, and repeat operations.
Results and limitations
Patients (mean age 10.5 yr) had a lower overall satisfaction score (27.1) than the physicians (30.6). Patients were least satisfied with overall genital appearance (3.1), penile length (3.3), and scars (3.3), whereas physician satisfaction was lowest for scars (3.5). The mean HOSE was 15.4 (standard deviation 0.9). Patients with acceptable HOSE (85%) had higher patient and physician satisfaction compared to patients with unacceptable HOSE. Patient satisfaction was lower among patients with a preoperative proximal meatal location or chordee, and with correction techniques other than the Mathieu approach. Physician satisfaction decreased with increasing patient age and was lower for patients with preoperative chordee, postoperative complications, or repeat operations.
Overall patient and physician satisfaction and clinical outcome scores were relatively high. Patient satisfaction was lower and based on different factors compared to physician satisfaction. Patient satisfaction seems more influenced by aesthetic appearance, but both patients and physicians appear to incorporate clinical characteristics and outcome in their opinion on satisfaction.
Different factors seem to influence patient and physician satisfaction with hypospadias correction, and there is only low correlation between the two. Therefore, patient satisfaction should be evaluated properly instead of making assumptions based on physician satisfaction or clinical outcome only.
Keywords: Hypospadias, Patient satisfaction, Perception, Questionnaires, Treatment outcome, Urogenital surgical procedures.
Hypospadias is a congenital malformation with an estimated prevalence in Europe ranging between 0.5 and 3.8 per 1000 live births , , and . In most cases, surgical correction is indicated , with the aim being to achieve normal micturition without spraying, a straight erection, and aesthetic satisfaction  and .
Postoperative patient satisfaction is important because of its influence on the child's psychological development . Physician satisfaction with surgical outcome is expected to correlate with that of the patient. Weber et al  found good patient-physician agreement, with higher satisfaction scored by patients than by independent surgeons. However, a similar study by Mureau et al  found opposite results.
Good postoperative clinical outcome is expected to result in high patient satisfaction. Other factors may influence the satisfaction of the patient and his parents, such as the meatal location, as a determinant of hypospadias severity , and the correction technique used. Many techniques have been associated with different types of complications and aesthetic outcomes , , , and , but no ideal correction method has been described , , , and . Age between 6 and 12 mo currently seems to be the preferred time for performing the correction . Results on the influence of the child's age and adolescence on patient satisfaction are inconsistent  and . For most patients, a one-stage procedure can be performed  and . Multistage procedures are only advised for more complicated forms of hypospadias . The rate of complications, such as urethrocutaneous fistula, wound dehiscence, and stricture, ranges from 5% to 50% for one-stage procedures , , and . Complications and the need for repeat operation may impact patient satisfaction. However, not all complications need surgical repair, and some repeat operations are only performed for dissatisfying aesthetic results .
Even though patient/parent satisfaction is important for the psychological well-being of patients born with hypospadias, and it has been suggested that several patient and treatment characteristics influence patient satisfaction, these factors have been investigated in only one study. Therefore, the goal of this study was to analyse patient/parent satisfaction with surgical outcome after hypospadias correction and to determine the association with physician satisfaction, as well as the influence of patient and treatment characteristics.
2. Patients and methods
Between 1996 and 2010, 238 patients had surgery for hypospadias performed by paediatric plastic surgeons in the Medical Centre Leeuwarden (MCL), a teaching hospital for plastic surgery in the Netherlands. Hypospadias surgery is part of the plastic surgery curriculum and has been performed by plastic surgeons in this hospital with special consultation hours, together with a paediatric nurse and medical social worker, for many years. The hospital provides care for patients from a large part of the north of the Netherlands. From the hypospadias patients, those requiring urethra reconstruction were selected. We excluded patients lost to follow-up because of emigration and those with incomplete hospital charts or whose previous or final treatment was carried out elsewhere. The minimum follow-up was set at 1 yr after first surgery and there were no age limits.
Between October 2011 and February 2012, all patients and their parents were invited by mail to participate in this study. Patients who did not wish to participate were asked for the reason why. Nonresponders were sent a reminder after a few weeks. The study was approved by the local ethics committee, and patients and/or their parents gave written informed consent before inclusion. The participants visited the outpatient clinic for a (regular) check-up, comprising an interview and physical examination performed by an independent physician (E.D.) not involved in previous or future treatment. Photographs of the genital appearance were taken, as is done for all hypospadias patients during previous preoperative and postoperative check-ups as part of our regular protocol.
Satisfaction with surgical outcome was measured using a standardised questionnaire developed in the Netherlands by Mureau et al , consisting of eight questions about different genital aspects, ranging from meatus position to scars and penile appearance in general. Satisfaction with each aspect was rated on a 4-point scale, where 1 denotes very dissatisfied and 4 indicates very satisfied. The overall minimum score is 8 and the maximum is 32. The questionnaire was filled out at home before the hospital appointment by the patient and/or his parent(s), which means that patient satisfaction in this study is a mixture of patient and parent satisfaction. After physical examination, the same questionnaire was filled out by the independent physician, who was blinded to the results reported by the patients/parents.
Clinical outcome was measured by the independent physician according to the Hypospadias Objective Scoring Evaluation (HOSE), a validated objective scoring method to assess surgical outcome after hypospadias corrections . HOSE consists of five domains: meatal location, meatal shape, urinary stream, erection, and fistula. Meatal location and shape and fistula presence were identified on physical examination. Erection and urinary stream were not physically evaluated, but determined by interviewing the child and his parents. The minimum total HOSE score is 5 and the maximum is 16. Holland et al  suggested that an acceptable outcome should have a total score of ≥14 with at least a meatus at the proximal glans, a single urinary stream, and only moderate angulation.
2.1. Patient and treatment characteristics
The patient and treatment characteristics analysed for their influence on satisfaction were as follows: preoperative meatal location; presence of preoperative chordee; number of planned surgeries to correct the hypospadias (staging); reconstructive type and timing of surgery; child's age during the study; postoperative complications; and repeat operations performed. Medical information was collected from hospital charts.
Meatal location was defined according to the preoperative location of the urethral opening and classified as glanular (glanular and coronal hypospadias), distal (subcoronal, distal penile, and mid-shaft hypospadias), or proximal (proximal penile, penoscrotal, midscrotal, and perineal hypospadias). Chordee was classified as moderate (angulation ≤45°) or severe (angulation >45°), mostly evaluated for an artificial erection at the start of surgery. Staging of the reconstruction was categorised as one-stage or multistage. The timing of the (first) urethroplasty was categorised in three age groups: <1 yr, 1–4 yr, and >4 yr. Using age during the study, patients were classified as <12 yr, 12–17 yr, or ≥18 yr. Repair techniques were described as a Mathieu repair or other type. In our hospital, the preferred technique for glanular and distal hypospadias is a modified form of the Mathieu repair, consisting of the regular Mathieu technique plus the creation of wings from the glans that are placed over the neourethra. The shaft is closed using a rotation advancement of the penile skin. A urethral catheter remains in place for 7 d. After normal micturition, the patient is discharged. The Mathieu repair is used because it is a relatively simple technique and has a low complication rate. Moreover, results are in general stable over time.
Complications were described as urinary tract infections or wound dehiscence developed within 1 mo after surgery, urethrocutaneous fistulas, prepuce-related complications (eg, phimosis or skin surplus), or other complications that developed at any time during follow-up. Complications were classified on the basis of whether they were corrected by repeat operation or not. Repeat operations were defined as any unexpected hypospadias-related surgery performed after the initial correction.
2.2. Statistical analyses
To describe differences in satisfaction and clinical outcome between patients and physicians, the mean and standard deviation were used for continuous variables, and the frequency and percentage for categorical variables. For comparison between patient and physician satisfaction, a paired t-test was used. The correlation of satisfaction between these two groups and between satisfaction and clinical outcome was tested using the Pearson correlation test. To investigate whether different patient and treatment characteristics influenced patient or physician satisfaction, Student's t-test was performed for dichotomous variables, and analysis of variance for variables with more than two categories.
3.1. Study population
Of the 205 invited patients, 75 participated. However, for one patient, both the patient and the physician satisfaction ratings were not completed, so this patient was left out of the analyses. Patient and treatment characteristics for patients who participated in the study were compared to those for the total group of patients invited to see whether selection bias was present. No apparent differences were found, apart from a slightly younger age and a higher percentage of corrections performed before the age of 1 yr in the participant group (Table 1).
Patient and treatment characteristics of participants and the total group of invited patients
|(n = 74)||(n = 205)|
|Preoperative meatal location a|
|Glanular||19 (25.7)||48 (23.5)|
|Distal||50 (67.6)||145 (71.1)|
|Proximal||5 (6.8)||11 (5.4)|
|Preoperative chordee b|
|No||44 (60.3)||122 (60.1)|
|Yes||29 (39.7)||81 (39.9)|
|Severity of the chordee c|
|Moderate||9 (40.9)||25 (39.7)|
|Severe||13 (59.1)||38 (60.3)|
|Staging of correction|
|One-stage||56 (75.7)||159 (77.6)|
|Multistage||18 (24.3)||46 (22.4)|
|Type of correction technique d|
|Mathieu||65 (87.8)||176 (85.9)|
|Other||9 (12.2)||29 (14.1)|
|Age at first urethra reconstruction|
|<1 yr||60 (81.1)||125 (61.0)|
|1–4 yr||9 (12.2)||58 (28.3)|
|>4 yr||5 (6.8)||22 (10.7)|
|Age at time of study|
|<12 yr||53 (71.6)||125 (61.0)|
|12–17 yr||18 (24.3)||69 (33.7)|
|≥18 yr||3 (4.1)||11 (5.4)|
|No||51 (68.9)||141 (68.8)|
|Yes||23 (31.1)||64 (31.2)|
|Repeat operation f|
|No||54 (73.0)||151 (73.7)|
|Yes||20 (27.0)||54 (26.3)|
a Preoperative meatal location was missing for 1 invited patient.
b Preoperative chordee was missing for 1 participant and 2 invited patients.
c Severity of the chordee could not be determined in 7 participants and 18 invited patients.
d A modified Mathieu correction was used. Examples of other types of repair are Duckett repair and tubularised incised plate urethroplasty.
e Complications were defined as a urinary tract infection or wound dehiscence that developed within 1 mo after surgery, or urethrocutaneous fistula, prepuce-related complications, or other complications that developed at any time during follow-up.
f Repeat operation was defined as any unexpected hypospadias-related surgery performed after the initial correction.
Data are presented as n (%).
The mean age of the participants at time of the study was 10.5 yr (standard deviation [SD] 6.5). The original meatal location was glanular in 26%, distal in 68%, and proximal in 7% of the patients. Chordee was present in 29 patients (40%). Other defects seen were pinpoint meatus (n = 11), penoscrotal web (n = 11), penile rotation (n = 2), bifid scrotum (n = 1), and a split glans (n = 1). Surgery was performed by five different surgeons, all of whom were certified plastic surgeons. One surgeon performed the urethroplasty in 77% of the cases. A modified Mathieu correction was performed as a one-stage procedure in 51 patients, and as a multistage procedure in 14 patients. In the latter group, the Mathieu correction was preceded by meatotomy and/or chordectomy. Other techniques used were Duckett repair (n = 4), tubularised incised plate urethroplasty (n = 2), Cecil-Culp repair (n = 2) and onlay island flap (n = 1), varying for the different phenotypes. A prepuce reconstruction was performed in 22% of the patients. Complications were seen in 23 patients, of whom three had more than one complication. Urinary tract infections were seen in two patients, wound dehiscence in four, fistulas in 15, and prepuce-related complications in five. No other complications were observed.
Satisfaction questionnaires were filled out by 65 patients or parents, although six were incomplete. Twenty were completed by the patient himself, 17 by parents, 19 by the patient and (one of) the parent(s), and for three patients it was unknown who filled out the questionnaire. The physician satisfaction could be determined for 73 patients. One patient did not allow a physical examination. The clinical outcome for this patient was assessed from medical photographs.
Patients/parents and the physician gave a maximum overall satisfaction score of 32 for 16 (27%) and 36 (49%) patients, respectively. A satisfaction score ≥24, covering a satisfaction range from slightly satisfied to very satisfied, was given by 46 patients (78%), and for all patients when scored by the physician. Mean overall patient satisfaction (27.1, SD 4.51) was lower than mean overall physician satisfaction (30.6, SD 1.78; p < 0.001; Table 2). For all items, patient satisfaction was lower than physician satisfaction. Patients had the lowest satisfaction score for penile length, scars, and overall genital appearance, whereas physicians had the lowest score for scars. Correlations existed between patient and physician scores for meatal location, scars, and total satisfaction, although they were low (ρ < 0.41).
Satisfaction with different genital aspects measured using Mureau's questionnaire and correlation between patient and physician satisfaction
|Mean satisfaction score (SD)||p value a||Pearson correlation|
|Patient (n = 59)||Physician (n = 73)||Coefficient||p value|
|Penile length||3.32 (0.86)||3.82 (0.46)||<0.001||0.23||0.08|
|Penile thickness||3.47 (0.78)||3.92 (0.28)||<0.001||0.10||0.43|
|Glanular shape||3.45 (0.69)||3.94 (0.31)||<0.001||−0.02||0.91|
|Glanular size||3.56 (0.56)||3.98 (0.13)||<0.001||−0.10||0.43|
|Location of the meatus||3.41 (0.87)||3.67 (0.71)||0.02||0.37||0.002|
|Scars||3.32 (0.88)||3.51 (0.76)||0.10||0.41||0.001|
|Scrotum||3.63 (0.63)||3.98 (0.13)||<0.001||−0.08||0.56|
|Overall genital appearance||3.14 (0.96)||3.77 (0.50)||<0.001||0.14||0.28|
|Total||27.1 (4.51)||30.6 (1.78)||<0.001||0.29||0.03|
a Paired t-test.
SD = standard deviation.
3.3. Clinical outcome
HOSE could be determined for 73 patients (Table 3). The mean HOSE was 15.4 (SD 0.94). In total, 44 patients (60%) had the maximum HOSE score of 16. Overall, differences in patient satisfaction were observed for all HOSE items, including the total score. Lower satisfaction scores were observed for a circular meatal shape, angulation in erection, and a fistula, but were not statistically significant. Differences in physician satisfaction for the HOSE items were less pronounced, but were all statistically significant except for meatal shape. Clinical outcome had a lower correlation with patient satisfaction (ρ = 0.36) than with physician satisfaction (ρ = 0.51; p < 0.01).
Influence of postoperative clinical outcome, measured with the Hypospadias Objective Scoring Evaluation (HOSE), on overall patient and physician satisfaction
|Overall patient satisfaction (n = 59)||Overall physician satisfaction (n = 73)|
|Mean (SD)||n||p value||Mean (SD)||n||p value|
|Distal glanular||27.2 (4.52)||54||30.9 (1.41)||67|
|Proximal glanular||26.8 (4.82)||5||0.86||27.5 (2.35)||6||< 0.001|
|Vertical slit||27.4 (4.30)||56||30.5 (1.78)||68|
|Circular||23.0 (7.21)||3||0.10||31.8 (0.45)||5||0.12|
|Single stream||27.4 (4.39)||51||30.8 (1.54)||63|
|Spray||25.8 (5.29)||8||0.35||29.4 (2.50)||10||0.02|
|Straight||27.7 (4.18)||51||30.8 (1.56)||65|
|Mild angulation||25.3 (6.11)||3||28.3 (4.04)||3|
|Moderate angulation||24.5 (5.07)||4||0.28||29.5 (1.73)||4||0.03|
|None||27.6 (4.52)||49||30.9 (1.65)||62|
|Single: subcoronal or more distal||25.8 (3.43)||6||29.0 (1.63)||7|
|Single: proximal||23.0 (3.92)||4||0.11||29.8 (2.22)||4||0.02|
|Acceptable outcome b and c|
|Yes||27.6 (4.22)||49||30.9 (1.28)||61|
|No||26.0 (5.00)||9||0.33||29.2 (2.48)||11||0.05|
a Curvature of the erection could not be described by the patient or his parents in 1 case.
b Acceptable outcome was defined as a total HOSE score of ≥14 with at least a proximal meatus, a single urinary stream, and only moderate angulation.
c The total HOSE score could not be determined for 1 patient.
SD = standard deviation.
3.4. Influence of patient and treatment characteristics on satisfaction
Patient satisfaction was lower among patients with preoperative proximal hypospadias or chordee, and for those who underwent a correction technique other than Mathieu repair (Table 4). Multistage operations, patient age ≥18 yr during the study, and the occurrence of complications, especially those for which there was no repeat operation, had lower satisfaction scores, although these were not statistically significant. Physician satisfaction was higher among patients without preoperative chordee and in the age group < 12 yr. Physician satisfaction was lower after the occurrence of complications, especially for those for which there was a repeat operation.
Influence of patient and treatment characteristics on overall patient and physician satisfaction
|Overall patient satisfaction (n = 59)||Overall physician satisfaction (n = 73)|
|Mean (SD)||n||p value||Mean (SD)||n||p value|
|Preoperative meatal location|
|Glanular||26.4 (4.63)||14||30.8 (1.40)||19|
|Distal||27.9 (4.33)||41||30.7 (1.67)||50|
|Proximal||22.0 (1.83)||4||0.03||28.8 (3.40)||4||0.09|
|No||28.5 (3.92)||34||31.1 (1.45)||43|
|Yes||25.0 (4.57)||24||0.003||29.9 (1.98)||29||0.01|
|Staging of correction|
|One-stage||27.8 (4.41)||43||30.8 (1.63)||55|
|Multistage||25.4 (4.46)||16||0.08||30.1 (2.04)||18||0.12|
|Type of correction technique a|
|Mathieu||27.7 (4.31)||53||30.8 (1.62)||64|
|Other||21.8 (2.14)||6||< 0.001||29.7 (2.40)||9||0.08|
|Age at first urethra reconstruction|
|<1 yr||27.4 (4.42)||49||30.7 (1.82)||59|
|1–4 yr||26.0 (5.32)||7||30.9 (1.63)||9|
|>4 yr||26.0 (5.20)||3||0.69||29.6 (1.52)||5||0.39|
|Age at time of the study|
|<12 yr||27.4 (4.31)||42||31.0 (1.52)||52|
|12–17 yr||26.9 (5.19)||15||29.9 (2.13)||18|
|≥18 yr||23.0 (0.00)||2||0.40||28.7 (0.58)||3||0.01|
|Complications b and repeat operations c|
|No complication, no repeat operation||27.8 (4.70)||35||31.2 (1.40)||48|
|No complication, but repeat operation||32.0 (0.00)||2||31.0 (1.41)||2|
|Complication, no repeat operation||23.2 (4.92)||5||30.2 (1.30)||5|
|Complication and repeat operation||26.4 (3.35)||17||0.06||29.2 (2.02)||18||<0.001|
a A modified Mathieu correction was used. Other types of repair were, for example, Duckett repair and tubularised incised plate urethroplasty.
b Complications were defined as a urinary tract infection or wound dehiscence that developed within 1 mo after surgery, or urethrocutaneous fistula, prepuce-related complications, or other complications that developed at any time during follow-up.
c Repeat operation was defined as any unexpected hypospadias-related surgery performed after the initial correction.
SD = standard deviation.
In this study, 23 patients had complications, of whom five did not undergo a repeat operation. Three of those had only minor dehiscence of the urethra or prepuce, which healed spontaneously. The other two had a fistula. Even though only one of these patients wanted a reconstruction, the satisfaction scores given by both patients was low (scores of 23 and 24). Two patients in this study had a repeat operation in the absence of any complication. These repeat operations were performed because of aesthetic dissatisfaction on the part of the patient and/or his parent(s). Patient satisfaction after repeat operation was the maximum score (32.0) for both patients.
When we excluded patients with a proximal form of hypospadias (n = 4) and patients aged ≥18 yr during study (n = 2), the differences in patient satisfaction between the categories were less pronounced (data not shown).
Overall patient/parent and physician satisfaction and clinical outcome scores were relatively high, but patients were less satisfied than the physician for all parts of the satisfaction questionnaire. Patients seemed to base their satisfaction on different aspects compared to the physicians. Overall patient satisfaction was associated with the preoperative meatal location, type of correction, and satisfaction with meatal shape, penile length, and genital appearance. Physician satisfaction was more associated with postoperative meatal location and patient age during the study. Factors influencing both were preoperative presence of chordee, clinical outcome, postoperative complications, and repeat operations.
Although overall patient satisfaction was lower than overall physician satisfaction, this was not true for every patient and for every item, resulting in a low correlation between patient and physician scores. Our results correspond with those of Mureau et al , but are in contrast to findings reported by Weber et al . The latter study used a panel of blinded urologists to score physician satisfaction, which could be one of the explanations for these differences. Some say that young age is associated with higher patient satisfaction  and , but the mean age of patients in our and the other studies did not differ. Weber et al  differentiated patient satisfaction from that of their parents, and found that parents were less satisfied. This differentiation was not analysed in our study because of limited power. However, most questionnaires (64%) in our study were filled out by or with the help of parents, which could explain the lower satisfaction.
In our study, penile length was one of the items that scored especially low on patient satisfaction. Even though this parameter is not changed by surgery, some studies show that in general, satisfaction with penile length influences patient satisfaction . General penile satisfaction is found not to be associated with actual length of the penis , but with satisfaction about penile length  and . In contrast to Weber et al , satisfaction with penile length was measured with the questionnaire used in our study and that of Mureau et al .
The influence of original and postoperative meatal location on satisfaction is controversial. In our study, patients with preoperative proximal hypospadias were less satisfied than patients with glanular or distal hypospadias, which is supported by some studies  and  but not by all , , and . Some studies found that the postoperative meatal location influenced patient satisfaction  and , but we did not find this association, although physician satisfaction seemed to be influenced by this.
Satisfaction was expected to be positively influenced by a good clinical outcome. However, the correlation between (patient) satisfaction and HOSE was rather low. A good explanation for this discrepancy is that although HOSE seems to be an adequate instrument to measure clinical outcome, it only partly evaluates functional outcome and does not evaluate all aesthetic aspects, such as the prepuce and scars. In our hospital, a prepuce reconstruction is performed if the situation allows it, and we think that scoring of this item would be a good contribution to the evaluation system.
Complications had a negative influence on patient satisfaction, despite repeat operation. However, patient satisfaction was higher among patients with a complication when a repeat operation was performed compared to when no repeat operation. For most of the patients in the latter group, no repeat operation was performed because the complication had healed spontaneously. However, patients in this group were still unsatisfied. Conversely, two other patients without complications who underwent a repeat operation for aesthetic reasons gave the maximum satisfaction score. These findings stress the importance of a repeat operation in some patients, even for dissatisfying aesthetic results.
Many techniques have been described for hypospadias surgery, with varying results. The Mathieu repair has existed for quite some time, and our department has wide experience with this technique, with good results. The main hypospadias surgeon performed a one-stage Mathieu repair in approximately 66% of the cases, which makes the study population quite homogeneous. Comparison of clinical outcome and satisfaction after hypospadias correction has previously been reported  and , but our study combined patient and physician satisfaction, clinical outcome measured using HOSE, and several patient and treatment characteristics.
With 74 of the 205 eligible patients actively participating and 59 patients with complete information, the number of patients included in our study was rather low (36% and 29%, respectively). Reasons for not participating ranged from not wanting to recall the intense treatment period to no interest because they had forgotten about the treatment. Some refused participation because we combined this study with a study involving blood sampling for DNA analyses. There was a low number of patients with proximal hypospadias (6.8%) in our study and only three children aged ≥18 yr (4.1%); however these percentages are comparable to those in the group of invited patients. Therefore, there seems to be no evidence of selective patient participation.
An acceptable clinical outcome does not always provide the best patient satisfaction. In this study, total patient and physician satisfaction and clinical outcomes were relatively high, but patients were less satisfied than physicians. Patient satisfaction seemed to be more influenced by aesthetic appearance, but both patients and physicians appeared to incorporate clinical characteristics and outcome in their opinion on satisfaction. Considering these differences, patient satisfaction should be evaluated properly instead of making assumptions based on physician satisfaction or clinical outcome only.
Conflict of interest
The authors have nothing to disclose.
-  F.H. Pierik, A. Burdorf, J.R. Nijman, S.M. de Muinck Keizer-Schrama, R. Juttmann, R.F. Weber. A high hypospadias rate in The Netherlands. Hum Reprod. 2002;17:1112-1115
-  J.E. Bergman, M. Loane, M. Vrijheid, et al. Epidemiology of hypospadias in Europe: a registry-based study. World J Urol. 2015;:1-9
-  K.B. Nissen, A. Udesen, E. Garne, Hypospadias: prevalence, birthweight and associated major congenital anomalies. Congenit Anom (Kyoto). 2015;55:37-41
-  A.T. Hadidi, A. Azmy. Hypospadias surgery: an illustrated guide. (Springer, Berlin, 2004)
-  A.R. Shukla, R.P. Patel, D.A. Canning. Hypospadias. Urol Clin North Am. 2004;31:445-460
-  B.C. Jones, M. O’Brien, J. Chase, B.R. Southwell, J.M. Hutson. Early hypospadias surgery may lead to a better long-term psychosexual outcome. J Urol. 2009;182:1744-1750
-  D.M. Weber, V.B. Schönbucher, M.A. Landolt, R. Gobet. The Pediatric Penile Perception Score: an instrument for patient self-assessment and surgeon evaluation after hypospadias repair. J Urol. 2008;180:1080-1084
-  M.A. Mureau, F.M. Slijper, A.K. Slob, F.C. Verhulst, R.J. Nijman. Satisfaction with penile appearance after hypospadias surgery: the patient and surgeon view. J Urol. 1996;155:703-706
-  L.S. Baskin, M.B. Ebbers. Hypospadias: anatomy, etiology, and technique. J Pediatr Surg. 2006;41:463-472
-  W.T. Snodgrass, N. Bush, N. Cost. Tubularized incised plate hypospadias repair for distal hypospadias. J Pediatr Urol. 2010;6:408-413
-  J. Roberts. Hypospadias surgery past, present and future. Curr Opin Urol. 2010;20:483-489
-  D.J. Wilkinson, P. Farrelly, S.E. Kenny. Outcomes in distal hypospadias: a systematic review of the Mathieu and tubularized incised plate repairs. J Pediatr Urol. 2012;8:307-312
-  A.T. Hadidi. The slit-like adjusted Mathieu technique for distal hypospadias. J Pediatr Surg. 2012;47:617-623
-  M. Imamoğlu, H. Bakırtaş. Comparison of two methods — Mathieu and Snodgrass — in hypospadias repair. Urol Int. 2003;71:251-254
-  E. Kass, S. Kogan, C. Manley, et al. Timing of elective surgery on the genitalia of male children with particular reference to the risks, benefits, and psychological effects of surgery and anesthesia. Pediatrics. 1996;97:590-594
-  V.B. Schönbucher, M.A. Landolt, R. Gobet, D.M. Weber. Health-related quality of life and psychological adjustment of children and adolescents with hypospadias. J Pediatr. 2008;152:865-872
-  L. Baskin, Hypospadias:. a critical analysis of cosmetic outcomes using photography. BJU Int. 2001;87:534-539
-  L.S. Baskin. Hypospadias and urethral development. J Urol. 2000;163:951-956
-  J.E. Nuininga, R.P. De Gier, R. Verschuren, W.F. Feitz. Long-term outcome of different types of 1-stage hypospadias repair. J Urol. 2005;174:1544-1548
-  M. Cimador, S. Vallasciani, G. Manzoni, W. Rigamonti, E. De Grazia, M. Castagnetti. Failed hypospadias in paediatric patients. Nat Rev Urol. 2013;10:657-666
-  A. Holland, G. Smith, F. Ross, D. Cass, HOSE:. an objective scoring system for evaluating the results of hypospadias surgery. BJU Int. 2001;88:255-258
-  M.A. Mureau, F.M. Slijper, R.J. Nijman, J.C. van der Meulen, F.C. Verhulst, A.K. Slob. Psychosexual adjustment of children and adolescents after different types of hypospadias surgery: a norm-related study. J Urol. 1995;154:1902-1907
-  K. Moriya, H. Kakizaki, H. Tanaka, et al. Long-term cosmetic and sexual outcome of hypospadias surgery: norm related study in adolescence. J Urol. 2006;176:1889-1893
-  S.P. Rynja, G.A. Wouters, M. Van Schaijk, E.T. Kok, T.P. De Jong, L.M. De Kort. Long-term followup of hypospadias: functional and cosmetic results. J Urol. 2009;182:1736-1743
-  C. Jiao, R. Wu, X. Xu, Q. Yu. Long-term outcome of penile appearance and sexual function after hypospadias repairs: situation and relation. Int Urol Nephrol. 2011;43:47-54
-  S. Rynja, T. de Jong, J. Bosch, L. de Kort. Functional, cosmetic and psychosexual results in adult men who underwent hypospadias correction in childhood. J Pediatr Urol. 2011;7:504-515
-  D.M. Weber, M.A. Landolt, R. Gobet, M. Kalisch, N.K. Greeff. The Penile Perception Score: an instrument enabling evaluation by surgeons and patient self-assessment after hypospadias repair. J Urol. 2013;189:189-193
a Department of Plastic Surgery and Hand Surgery, Medical Centre Leeuwarden, Leeuwarden, The Netherlands
b Department for Health Evidence, Radboud University Medical Centre, Nijmegen, The Netherlands
Corresponding author. Department for Health Evidence, Radboud University Medical Centre, P.O. Box 9101, 6500 HB Nijmegen, The Netherlands. Tel. +31 2436 67262; Fax: +31 2436 13505.
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