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Letter to the Editor

Reply to Lei Kang, Lugang Huang and Jingti Zhang’s

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 thank Dr. Zhang and colleagues


for their letter

regarding our article

[2] .

With regards to their comments,

we would like to clarify the following aspects on our study.

It is well known that the outcome of reconstructive

surgeries is widely variable and surgical experience is of

utmost importance for optimized outcomes. This makes

identification of clear guidelines for reconstructive surgery

very challenging. Prospective randomized trials are lacking

in this field given the clinical variation between cases as it is

typical for hypospadias anomalies. This circumstance

makes retrospective data an important source for practice

improvement. The aim of our article was to provide

scientific evidence for optimized urethral coverage during

tubularized incised plate urethroplasty and not to prove the

superiority of one flap technique over the other. We suggest

that this analysis may especially be helpful for surgeons

who are still in their learning phase rather than for expert


Regarding the three studies suggested to be excluded

from our analysis, we would like to clarify that the study by

Bilici et al


was not included in the double dartos fascia

(DF) subgroup; Bilici and colleagues


reported on two

groups and only the group without spongioplasty was

included in our analysis under the single DF subgroup. The

other group with spongioplasty was excluded. We consid-

ered the study by Babu and Hariharasudhan


eligible for

our analysis despite spongioplasty because spongioplasty

was performed in all patients in both DF and tunica

vaginalis flap (TVF) groups, so the impact of spongioplasty

theoretically would be the same in both groups and still can

be compared regarding usage of DF versus TVF which was,

in fact, the main aim for the review. The reason why we

considered the study by Seo et al


despite usage of

external spermatic fascia was that they used the same

surgical technique for harvesting TVF either by separate

scrotal incision or delivery of the tests through the penile

wound. As this technique still carries the same theoretical

complications for TVF regarding testicular injury, vascular

injury, torsion, etc., which are, in our view, the main

obstacles for surgeons with regards to the use of TVF, we

considered that inclusion of this study would be more

valuable to the analysis than exclusion, especially given the

few publications on TVF.

Finally, we agree that inclusion of more databases

in research processes might increase article retrieval.

However, at least one database is still the minimum

requirement according to Preferred Reporting Items for

Systematic Reviews and Meta-analyses criteria and the

Preferred Reporting Items for Systematic Reviews and

Meta-analyses checklist


, which we followed during our

review process.

Conflicts of interest:

The authors have nothing to disclose.



Kang L, Huang L,


Zhang J, 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, Eur Urol 2017;71:e154.


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



Bilici S, Sekmenli T, Gunes M, Gecit I, Bakan V, Isik D. 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



Babu R, Hariharasudhan S. Tunica vaginalis flap is superior to inner preputial dartos flap as a waterproofing layer for primary TIP repair in midshaft hypospadias. J Pediatr Urol 2013;9:804–7.


Seo S, Ochi T, Yazaki Y, et al. Soft tissue interposition is effective for protecting the neourethra during hypospadias surgery and pre- venting postoperative urethrocutaneous fistula: a single surgeon’s experience of 243 cases. Pediatr Surg Int 2015;31:297–303.


Moher D, Shamseer L, Clarke M, et al. Preferred reporting items for systematic review and meta-analysis protocols (PRISMA-P) 2015 statement. Syst Rev 2015;4:1


E U R O P E A N U R O L O G Y 7 1 ( 2 0 1 7 ) e 1 5 5 – e 1 5 6

ava ilable at

journal homepage:

DOIs of original articles:





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