The degree of chordee associated with hypospadias impacts operative management. Unfortunately, poor inter-observer reliability in assessing chordee by multiple methods in vitro has been demonstrated. This variability may be related to the fact that chordee is not a discrete angle, but rather an arc-like curvature similar to that of a banana. On an attempt to improve this variability, we assessed the inter-rater reliability of a novel method of chordee measurement and compared it to measurements with a goniometer both in vitro and in vivo.
Materials and methods
In vitro assessment of curvature was performed using 5 bananas. In vivo chordee measurement was performed during 43 hypospadias repairs. On in vitro and in vivo cases, chordee was assessed independently by faculty and resident physicians. Angle assessment was performed in a standard manner with a goniometer and with a smartphone app using ruler measurements of the length and width of the arc (Summary Figure). The proximal and distal aspect of the arc to be measured was marked on the bananas, whereas the penile measurements were taken from the penoscrotal to the sub-coronal junctions.
In vitro banana assessment demonstrated strong intra- and inter-rater reliability for length (0.89 and 0.88, respectively) and width measurements (0.97 and 0.96). The calculated angle demonstrated an intra- and inter-rater reliability of 0.67 and 0.67. The banana goniometer/protractor measurements were weak with an intra-rater and inter-rater reliability of 0.33 and 0.21. With hypospadias chordee, the inter-rater reliability was strong for length and width measurements (0.95 and 0.94) and 0.48 for calculated angle. The inter-rater reliability of the goniometer angle was 0.96. Further assessment of inter-rater goniometer reliability was performed relative to degree of chordee as characterized by faculty. The inter-rater reliability for ≤15°, 16–30, and ≥30° was 0.68 (n = 20), 0.34 (n = 14), and 0.90 (n = 9), respectively. When the goniometer angle was classified as ≤15, 16–30, or ≥30° by one physician, it was classified outside of this range by the other physician 23%, 47%, and 25% of the time, respectively.
Our data demonstrate significant limitations of the goniometer for assessing chordee in vitro and in vivo. We were unable to demonstrate significant improvement in chordee assessment using arc length and width measurements to calculate radians.
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Published online: February 07, 2023
Accepted: February 3, 2023
Received in revised form: February 1, 2023
Received: October 25, 2022
Publication stageIn Press Journal Pre-Proof
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- Hypospadias curvature assessment: Lessons learned in the banana lab!Journal of Pediatric Urology
- PreviewI read with interest the study by cooper et al. . I admire the authors' innovative approach to studying curvature. We demonstrated that hypospadiologists tend to underestimate the actual degree of curvature . This was also confirmed by Kern et al. in their recent survey of members of the SPU . 50% of their participants have been in practice for more than 20 years, however a penile model with “severe” curvature of 70° was estimated by participants to be 55° and only 60% reported they would use ventral lengthening (VL) to correct it .
- The need to optimize measurement of penile curvature in cases of hypospadiasJournal of Pediatric Urology
- PreviewI read the new article “What Is the Angle of a Banana? The Difficulty in Reliable Assessment of Hypospadias Chordee”  that outlines the in vitro and in vivo evaluation of a new penile curvature (PC) method. In addition, this is the first study to evaluate the inter-rater reliability of intraoperative penile measurement using a goniometer.
- Letter to the Editor reg: “Cooper CS et al., What is the angle of a banana? The difficulty in reliable assessment of hypospadias chordee, Journal of Pediatric Urology, https://doi.org/10.1016/j.jpurol.2023.02.003”Journal of Pediatric Urology
- PreviewWe read the paper by Cooper et al  with interest. They presumed that the penile curvature (PC) in hypospadias is not a discrete angulation, but more often an arc-like curvature (AC), thus comparing it with the curve of a banana! While we agree that the PC may not be a perfect hinge, the point of maximum PC is of definite interest in its correction. In fact most hypospadiologists are interested in the degree and location of angulation than the radian angle subtended by the arc. Thus, measuring radian using Arccalc application may be more of an academic exercise without any practical application in hypospadias surgery.