Assessment of postoperative cosmetic outcomes of distal form hypospadias repair with the Hypospadias Objective Scoring Evaluation (HOSE)

Abstract

Aim A standardized assessment for the optimal repair of hypospadias remains elusive. The aim of this study was to assess a postoperative cosmetic outcome of hypospadias repair using a validated questionnaire, Hypospadias Objective Scoring Evaluation (HOSE).
Methods During the period between January 2016 and May 2019, 40 patients who underwent hypospadias repair were identified and they agreed to a follow-up using the HOSE. Distal hypospadias repairs underwent a cross-sectional assessment of the cosmetic outcome. Cosmetic assessment was performed by an independent physician using the HOSE scoring system.
Results The native meatus was coronal in 10 (25%), subcoronal in eight (20%), and distal penile in 22 (55%) patients. Mean followup was 35.90 months (SD ±29.58) postoperatively (range 12–162 months). Complications occurred in one (2.5%) patient. Out of 40 uncomplicated repairs, 39 (97.5%) were satisfactory. A vertical slit-like meatus located at the distal glans was created in 33 (82.5%) boys, and at the proximal glans in seven (17.5%). The urinary stream was single and straight in 39 and spray in one patient. A straight erection was observed in 39 (97.5%) boys. The median HOSE score was 16 (range 12–16). One patient had a small, single coronal fistula. The technique used included tubularised incised plate urethroplasty.
Conclusion The HOSE score is simple, easy, non-invasive and non-expensive tool for objective assessment of long-term outcomes of hypospadias repair.

Full text

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ORIGINAL ARTICLE
Assessment of postoperative cosmetic outcomes of distal form
hypospadias repair with the Hypospadias Objective Scoring
Evaluation (HOSE)
Asmir Jonuzi1 , Zlatan Zvizdić 1, Emir Milišić1, Benjamin Kulovac2 , Amira Mešić3, Semir Vranić4,5
1Clinic of Paediatric Surgery, 2Clinic of Urology, 3Department of Anaesthesiology and Reanimation; Clinical Centre University in
Sarajevo, Sarajevo, Bosnia and Herzegovina, 4College of Medicine, 5Biomedical and Pharmaceutical Research Unit; QU Health, Qatar
University, Doha, Qatar
Corresponding author:
Asmir Jonuzi
Clinic of Pediatric Surgery,
Clinical Centre University in Sarajevo
Patriotske lige 81, Sarajevo,
Bosnia and Herzegovina
Phone: +387 33 250 345;
Fax: +387 33 250 334;
E-mail: jonuziasmir@hotmail.com
ORCID ID: https://orcid.org/0000-0002-
5637-9510
Original submission:
08 March 2022;
Revised submission:
31 March 2022;
Accepted:
05 May 2022
doi: 10.17392/1482-22
Med Glas (Zenica) 2022; 19(2):
ABSTRACT
Aim A standardized assessment for the optimal repair of hypos-
padias remains elusive. The aim of this study was to assess a po-
stoperative cosmetic outcome of hypospadias repair using a va-
lidated questionnaire, Hypospadias Objective Scoring Evaluation
(HOSE).
Methods During the period between January 2016 and May 2019,
40 patients who underwent hypospadias repair were identied and
they agreed to a follow-up using the HOSE. Distal hypospadias
repairs underwent a cross-sectional assessment of the cosmetic
outcome. Cosmetic assessment was performed by an independent
physician using the HOSE scoring system.
Results The native meatus was coronal in 10 (25%), subcoronal in
eight (20%), and distal penile in 22 (55%) patients. Mean follow-
up was 35.90 months (SD ±29.58) postoperatively (range 12–162
months). Complications occurred in one (2.5%) patient. Out of
40 uncomplicated repairs, 39 (97.5%) were satisfactory. A verti-
cal slit-like meatus located at the distal glans was created in 33
(82.5%) boys, and at the proximal glans in seven (17.5%). The uri-
nary stream was single and straight in 39 and spray in one patient.
A straight erection was observed in 39 (97.5%) boys. The median
HOSE score was 16 (range 12–16). One patient had a small, single
coronal stula. The technique used included tubularised incised
plate urethroplasty.
Conclusion The HOSE score is simple, easy, non-invasive and
non-expensive tool for objective assessment of long-term outco-
mes of hypospadias repair.
Key words: hypospadias, tubularised incised plate, urethra, uret-
hroplasty

145
Jonuzi et al. Assessment of cosmetic outcomes of hypospadias
INTRODUCTION
Hypospadias is a developmental defect of the
male urethra, either treated or untreated, and it
can have functional, cosmetic and psychosexu-
al consequences extending into adulthood (1,2).
The assessment of the cosmetic results after
hypospadias repair remains a problem due to
published studied showing possible signicant
differences between the patients´ judgement and
surgeons´ opinion (3). Traditionally, successful
repair of hypospadias was dened as straight pe-
nis in erection and a good calibre urethra with a
slit-like urethral meatus at the tip of the glans,
allowing micturition in a single coherent urinary
stream and allowing sexual intercourse (3). The
goal of the modern surgical treatment is to create
a functionally and cosmetically normal penis.
Distal hypospadias repair is one of the procedures
most commonly performed in paediatric urology
(4). Hypospadias is one of the most frequently
occurring birth defects in males, that affects 1 in
200 to 300 newborn males (4). The total preva-
lence of hypospadias in Europe is approximately
18.6/10,000 births (5).
Despite more than 200 different repair techniques
for hypospadias described in the literature, there
is no completely satisfactory technique in terms
of complications and cosmesis (6). Snodgrass re-
pair (7) was introduced in 1994 and has revolutio-
nised the management of distal hypospadias, and
is considered the procedure of choice by most sur-
geons. The technique relies on an incision of the
urethral plate to permit a tension-free tubularisa-
tion of the neourethra (8). According to Snodgra-
ss et al, in the standard technique as there is risk
of meatal stenosis (9,10). Thus, the neourethra is
reconstructed to the mid-glans level, and the neo-
meatus should be generously sized and oval at the
same time. This resulted in a higher rate of achie-
ving a slit-like meatus, but a lower rate of locating
the meatus in the glans tip (11). Histopathological
studies under the urethral plate have shown a he-
althy, vascularised connective subepithelial tissue
(12). Thus, incising the apical part of the glans
could be safe, to assign the neomeatus more to the
tip of the glans, and reconstruction the neourethra
more distally. Normally, the meatus is located at
the glans apex in 94% of boys (13) and the ventral
glans closure is equal to or slightly less than the
meatal length (14).
Many studies have so far focused on the com-
plication rates (3,9,10). Cosmetic results, instead,
have been studied less extensively (3) probably
because of evaluation of this kind of results is ge-
nerally considered difcult to standardize and it
is subjected to wide variability among observes
(9). Nevertheless, cosmesis remains a key point,
as in distal hypospadias patients surgery is of-
ten undertaken mainly to improve cosmesis and
prevent a potential psychological burden of the
malformation (3,4,8).
Validated scales, such as the Hypospadias Objec-
tive Scoring Evaluation (HOSE) (15) give the ad-
vantage of allowing surgeons to more objectively
assess postoperative outcomes, as well as provide
a platform for surgeons to discuss outcomes (3).
The HOSE is underused, although the use of such
a system is recommended by others (10,15).
In Bosnia and Herzegovina there are only scarce
investigations relating to hypospadia.
The aim of this study was to assess outcomes
of one-stage hypospadias repair at a paediatric
tertiary centre in Bosnia and Herzegovina using
HOSE.
PATIENTS AND METHODS
Patients and study design
During the period between January 2016 and
May 2019, 40 patients with primary distal hypos-
padias repaired with the Snodgrass technique at
the Clinic for Paediatric Surgery of the Clinical
Centre, University of Sarajevo, were included
in this prospective study. Patients with proximal
hypospadias, megameatus intact prepuce, and
those with a previously failed repair were exclu-
ded from the study. All patients received preope-
rative local androgen therapy, 2.5% dihidrotesto-
steron (DHT).
Prior to participation, an informed consent was
obtained from all patients by their parents. This
study was conducted in compliance with the et-
hical principles originating in or derived from
the Declaration of Helsinki and in compliance
with all International Council for Harmonisation
(ICH) Good Clinical Practice (GCP) Guidelines.
A formal approval for the medical records review
was obtained from the Ethics Committee of Cli-
nical Centre, University of Sarajevo.

Medicinski Glasnik, Volume 19, Number 2, August 2022
146
Methods
Selection of the technique was based on
physician’s preference and a surgical technique;
we used tubularised incised plate (TIP) (7). Mul-
tiple-layer coverage of the urethroplasty was
achieved using local dartos aps. Penile curva-
ture was always addressed by Nesbit plicatio (3).
All patients were invited by a telephone call to
their parents after three months to attend a consul-
tation clinic for a follow-up of their hypospadias
repair. Follow-up was dened as the time betwe-
en the date of operation and three months after
surgery. Patients included in the study were boys
with distal type of hypospadias form. Cosmetic
evaluation was made by an independent paedia-
tric urologist not previously involved in the care
of these patients.
The boys were interviewed and examined in the
presence of their parents by a surgeon; self-asse-
ssment and quality of life questionnaires were
then completed with an independent interviewer
to avoid bias when answering the questionnaires.
Parents were asked to complete the questionnaire.
The HOSE (15) was used in the follow-up. The
HOSE has been validated as a paediatric objecti-
ve scoring system for evaluating the outcomes of
hypospadias repair and incorporates the outcomes
of meatal location and shape, urinary stream, the
straightness of erection and any urethral stula:
the minimum total score of 5 corresponding to a
lowest score for each variable, to a maximum total
of 16 as equivalent to the highest score for each
variable. A score of 14-16 was suggested (15) to
infer an acceptable outcome with the meatus at le-
ast at the proximal glans, a single urinary stream
and only moderate angulation of the penile shaft.
These patients, whose score was 14-16 would
require further follow-up and additional diagno-
stics (uroowmetry in order to detect obstruction
of the urethra and the appearance of a stula, as
surgical complications). A score a below 14 was
considered not acceptable (15).
Statistical methods
Mean and median were used as a measure of cen-
tral tendency and standard deviation and range as
measures of dispersion for continuous variables.
The values of categorical variables were presen-
ted as numbers or percentages.
RESULTS
Of the total of all patients recruited in the stu-
dy, the mean age at surgery was 35.90 months
(29.58± SD) with a range 12-162 months.
Of the initial 40 patients, one (2.5%) developed
surgical complications including stula formati-
on. Of the remaining 39 patients without com-
plication, all were contacted and they agreed to
participate in the study. The native meatus was
coronal in 10 (25%) patients, subcoronal in eight
(20%) and distal penile in 22 (55%) patients.
Preoperatively, nine patients were reported to have
meatal stenosis at rst presentation, with six ha-
ving chordee. The procedure used included tubu-
larised incised plate (TIP) repair (7) in 40 patients.
The HOSE outcome data were obtained for all 40
patients: 39 (97.5%) had an acceptable score, and
one (2.5%) had a non-acceptable score.
Thirty eight (95%) patients achieved a vertical me-
atal shape, 2 (5%) achieved circular meatal shape,
39 (97.5%) achieving a single stream, 1 (2.5%)
achieving spray, 33 (82.5%) achieving distal gla-
nular meatal location and 7 (17.5%) achieving
proximal glanular. All patients except one, achie-
ved a straight erection with one patient experien-
cing mild angulation. One boy had a total HOSE
score of 12, with a subcoronal stula (Table 1).
HOSE variable No (%) of patients HOSE score
Meatal location
Distal glanular 33 (82.5) 4
Proximal glanular 7 (17.5) 3
Coronal 0 2
Penile shaft 0 1
Meatal shape
Vertical slit 38 (95.0) 2
Circular 2 (5.0) 1
Urinary stream
Single stream 39 (97.5) 2
Spray 1 (2.5) 1
Erection
Straight 39 (97.5) 4
Mild angulation (<10) 0 3
Moderate angulation (>10 but
<45) 1 (2.5) 2
Severe angulation (>45) 0 1
Fistula
None 39 (97.5) 4
Single-sub coronal 1 (2.5) 3
Single proximal 0 2
Multiple or complex 0 1
Total 40
Table 1. Outcome of hypospadias repair according to the
Hypospadias Objective Scoring Evaluation (HOSE)
According to the HOSE score, one (2.5%) pati-
ent had the score of 12, two (2.5%) had the score

147
of 14, three (7.5%) had the score of 15, and 34
(85%) patients had the score of 16 (Table 2).
The median HOSE score was 16 (range 12–16)
out of a maximum score of 16.
agreement between patient and surgeon satisfac-
tion with the patient’s penile appearance (19).
Afterwards, Holland et al. introduced the HOSE
system where paediatric surgeons, a nurse, and
one of the child’s parents independently evalua-
ted each patient (15).
Renements like using digital photography with
macro mode in a standardized fashion and with
more external expertise in judging outcome are
used (3). The assessment of cosmesis in hypos-
padias surgery was thought to be more objective
when several health non-surgeon professionals
compared various methods of repair (18). The
most recent attempt for objective assessment of
postoperative outcome is the Pediatric Penile Per-
ception Score (PPPS), which seems to be a relia-
ble instrument to assess cosmetic and functional
results in children after hypospadias repair (20).
The Hypospadias Objective Penile Evalua-
tion Score (HOPE) introduced by a national
study group from the Netherlands established
objectivity by using standardized photographs,
anonymously coded patients, and independent
assessment by a panel (21).
Thirty nine (97.5%) of our patients had an accep-
table HOSE outcome with a total score of 14 to
16, and one patient (2.5%) had an unacceptable
outcome with a total score of 12. It is difcult
to compare our HOSE scores with others as the
majority of published studies have used this met-
hod to assess the outcome of anterior hypospa-
dias repair (22). The meatal location, shape and
stula are easy for objective evaluation, but the
main drawback of the HOSE in our study arose
in relation to the necessity of objective evaluati-
on of the straightness of the penis. Nevertheless,
Holland et al. stated that erection can be gauged
after an erection is witnessed by an assessor or
can be based on parental evaluation (15).
The most appropriate postoperative follow-up
period for hypospadias has been debated in the li-
terature: routine follow-up periods appear to vary
widely — from schedules of 3 months, 6 months
and 1 year to longer (at 3 and 6 years) (23). In
our institution routine follow-up is every three
months in the rst year, and every 6 months in the
second year; after 2 years following the surgery
the patients come to control examination every
year (if uroow is normal).
HOSE score No (%) of patients
12 1 (2.5)
14 2 (5.0)
15 3 (7.5)
16 34 (85.0)
Total 40 (100.0)
Table 2. Frequency distribution according to the Hypospadias
Objective Scoring Evaluation (HOSE) score
DISCUSSION
In this study, we systematically assessed cosme-
tic results of TIP repair, and found that 97.5% had
satisfactory appearance. In distal hypospadias,
surgery is mainly undertaken to improve cosme-
sis and functional results, and we believe that the
correction of distal hypospadias is not a cosmetic
surgery and would recommend that all children
with hypospadias, regardless of the severity, sho-
uld be referred to a specialist paediatric urologist.
From the clinical point of view, continuous asse-
ssment of the outcome represents quality control
and is a part of clinical governance. Continuous
re-evaluation may have a major impact on future
clinical practice.
Most paediatric surgeons now prefer to use the TIP
to repair distal and mid-shaft hypospadias defects
(8,9). Postoperative outcomes have been empha-
sized to include functional, cosmetic, as well as
psychosocial outcomes, with longer term review
deemed to be necessary for adequate evaluation
of surgical success (3,16). Validated scales could
more objectively assess postoperative outcomes,
as well as long-term outcomes; moreover, they
can also be used as a screening tool, emailed as
an online survey or posted to evaluate which pa-
tients require further clinical consultation (17,18).
The lack of studies on the cosmetic results of distal
hypospadias surgery may partly account for dif-
culties in its standardization and being subjected to
wide variability among observes (3).
Mureau et al. were one of the rst to apply a stan-
dardized approach to evaluate both patient’s and
surgeon’s satisfaction with the cosmetic surgi-
cal result, and the relation among penile length,
meatal position, and patient satisfaction using a
genital perception questionnaire for hypospadias
patients. Not surprisingly, there was hardly any
Jonuzi et al. Assessment of cosmetic outcomes of hypospadias

Medicinski Glasnik, Volume 19, Number 2, August 2022
148
In a meta-analysis, complications rate form
hypospadias surgery have been reported in up to
33.3% of cases (24), in our study 2.5% complica-
tions rate (wound infection, haematuria, stula,
meatal stenosis, wide meatal opening and uret-
hral stricture have also been observed).
Surgical correction of distal hypospadias carri-
es minor risks, complication rates are relatively
low, but despite some variations among different
techniques, outcomes in the majority of cases are
successful (25). The most signicant advantage
of tubularised incised plate urethroplasty (TIPU)
is the excellent postoperative cosmetic appea-
rance, which is an important factor in choosing
the technique for hypospadias repair. In this pro-
cedure the urethral plate can be preserved, and
the tissue used for the neourethra is well vascu-
larized. The procedure can be easily learned and
performed and can be used in secondary and/or
proximal cases with satisfactory cosmetic outco-
me. When the long-term success rate and the
advantages of the technique are taken into con-
sideration, TIPU may be accepted as having an
important role in hypospadias treatment (26,27).
In conclusion, distal hypospadias can be asso-
ciated with cosmetic problems that may be un-
derestimated at birth and generate symptoms at
an older age.
The validated HOSE questionnaire revealed ge-
nerally good cosmetic outcomes after hypospa-
dias repair. The use of validated questionnaires in
routine follow-up sessions may facilitate objecti-
ve assessment and patient satisfaction.
FUNDING
Funding: no specic funding was received for
this study
TRANSPARENCY DECLARATION
Competing interests: None to declare.
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