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Letter to the Editor

Re: Omar Fahmy, Mohd Ghani Khairul-Asri, Christian

Schwentner, et al. Algorithm for Optimal Urethral

Coverage in Hypospadias and Fistula Repair:

A Systematic Review. Eur Urol 2016;70:293–8

We read with great interest the recent article by Fahmy et al


who reviewed techniques to identify the best urethral

coverage in tubularized incised plate (TIP) urethroplasty

and fistula repair. Without doubt, the authors have carried

out a meaningful and thorough review. Nevertheless, we

would like to make some comments on this issue.

TIP urethroplasty is currently the most popular tech-

nique used for hypospadias correction, especially for the

distal type, mainly because of its simplicity, reliability, and

superior cosmetic results


. Although use of a single-

layer or double-layer dartos fascia (DF) flap reduces the

fistula rate, it might complicate the simple technique.

Moreover, the greater the DF dissection, the greater is the

risk of skin complications. As the authors emphasized,

many studies included in the systematic review lacked

information regarding skin complications. However, skin

complications might represent a major drawback of the DF

technique, as reported by some studies (eg, refs. [35,53,54]

in the article). Therefore, vascular spongious tissue (spon-

gioplasty) should be a good choice for additional neourethral

coverage, and this technique would be conducive for

correction of chordee and penile torsion


. Spongioplasty

alone is usually sufficient during TIP urethroplasty for

distal hypospadias


. For cases with a poorly developed

spongiosum, spongioplasty plus a DF flap has been

suggested to minimize the complication rate



DF flaps for use as protective coverage can be harvested

from the inner layer of the prepuce, the dorsal or ventral

penile shaft, or the scrotum. Different DF sources may lead

to different outcomes because of differences in the degree of

development and dissection. Thus, we believe that the DF

should be divided and compared in subgroups.

In addition, one study (ref. [29] in the article) should be

excluded from the group of studies with a double-layer DF

flap since the neourethra was covered with paraurethral

spongious tissue plus a DF flap rather than a double-layer

DF flap, and another study (ref. [55] in the article) should be

excluded from the tunica vaginalis flap (TVF) group because

the neourethra was covered using external spermatic fascia.

Moreover, a further study (ref. [53] in the article) should be

excluded from the overall analysis since spongioplasty was

added in all cases beyond the use of DF flaps or TVF.

In summary, we believe that the literature retrieval

process should be as comprehensive as possible for a

systematic review; at the very least, the threemost important

databases (MEDLINE/PubMed, EMBASE, and Cochrane

Library–CENTRAL) should be searched. In addition, Boolean

logic can play a very helpful role during article retrieval.

Conflicts of interest:

The authors have nothing to disclose.



Fahmy O, Khairul-Asri MG, Schwentner C, et al. Algorithm for optimal urethral coverage in hypospadias and fistula repair: a systematic review. Eur Urol 2016;70:293–8.


Springer A, Krois W, Horcher E. Trends in hypospadias surgery: results of a worldwide survey. Eur Urol 2011;60:1184–9.


Wang F, Xu Y, Zhong H. Systematic review and meta-analysis of studies comparing the perimeatal-based flap and tubularized in- cised-plate techniques for primary hypospadias repair. Pediatr Surg Int 2013;29:811–21.


Bhat A, Sabharwal K, Bhat M. Outcome of tubularized incised plate urethroplasty with spongioplasty alone as additional tissue cover: a prospective study. Indian J Urol 2014;30:392–7



Yerkes EB, Adams MC, Miller DA, et al. Y-to-I wrap: use of the distal spongiosum for hypospadias repair. J Urol 2000;163:1536–8.


Bilici S, Sekmenli T, Gunes M, et al. Comparison of dartos flap and dartos flap plus spongioplasty to prevent the formation of fistulae in the Snodgrass technique. Int Urol Nephrol 2011;43:943–8.

Lei Kang


Lugang Huang


Jingti Zhang




Department of Urology, Xi’an Children’s Hospital, Xi’an Jiaotong University,

Xi’an, People’s Republic of China


Department of Pediatric Surgery, West China Hospital, Sichuan University,

Chengdu, People’s Republic of China

*Corresponding author. Department of Urology, Xi’an Children’s

Hospital, Xi’an Jiaotong University, 69 Xijuyuan Lane, Xi’an, Shaanxi

710003, People’s Republic of China. Tel. +86 18 991236756.

E-mail address:

(J. Zhang).

November 16, 2016

E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) e 1 5 4

available at


journal homepage:

DOI of original article:




2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.