Surgical process variables for the classification of hypospadias

I read the article published by the Western Pediatric Urology Consortium (WPUC) network on identifying variability in surgical practices and instruments used for hypospadias repair [ ]. Despite the authors' efforts, I think it is not possible to use this study to understand what variables can be reliably measured for future surgical outcomes in hypospadias. There are mainly two types of variables to measure in surgical research studies: patient outcomes and surgical process. In fact, almost all “variables” in this study are patient, surgeon and procedure-related confounding variables and/or contributing factors (such as patient classification as distal TIP and proximal hypospadias, level of expertise of practicing fellow surgeons, operative templates, tissues used, suture types and catheter selection, etc.), making it difficult to draw valid conclusions. Obviously, the variables and/or factors studied in this work cannot be correlated with the surgical outcomes. It is also interesting that the authors of WPUC classified the patients as having TIP and proximal hypospadias repairs. Unless it is a naïve approach, it needs to be discussed in detail. A hypospadias repair technique that violates the established anatomical facts cannot be used as the background to a scientific study attempting to identify the variables of hypospadias surgery. As I have mentioned in my previous reports, with glans dissection (ignoring the “septum glandis”), uniform tubularization of the neo-urethra (ignoring the “fossa navicularis”), and with the deep midline glans incision (ignoring and harming the “distal ligament”) TIPU is the biggest delusion in pediatric urology [ , , , ].