EURURO Vol. 71 No. 5

E155 844

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 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
surgeons.
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.
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0302-2838/# 2016 European Association of Urology. Published by Elsevier B.V. All rights reserved.