title: High GMS score hypospadias: Outcomes after one- and two-stage operations.
abstract: BACKGROUND
  Established criteria to assist surgeons in deciding between a one- or two-stage operation for severe hypospadias are lacking. While anatomical features may preclude some surgical options, the decision to approach severe hypospadias in a one- or two-stage fashion is generally based on individual surgeon preference. This decision has been described as a dilemma as outcomes range widely and there is lack of evidence supporting the superiority of one approach over the other.
  
  
  OBJECTIVE
  The aim of this study is to determine whether the GMS hypospadias score may provide some guidance in choosing the surgical approach used for correction of severe hypospadias.
  
  
  METHODS
  GMS scores were preoperatively assigned to patients having primary surgery for hypospadias. Those patients having surgery for the most severe hypospadias were selected and formed the study cohort. The records of these patients were reviewed and pertinent data collected. Complications requiring further surgery were assessed and correlated with the GMS score and the surgical technique used for repair (one-stage vs. two-stage).
  
  
  RESULTS
  Eighty-seven boys were identified with a GMS score (range 3-12) of 10 or higher. At a mean follow-up of 22 months the overall complication rate for the cohort after final planned surgery was 39%. For intended one-stage procedures (n = 48) an acceptable result was achieved with one surgery for 28 patients (58%), with two surgeries for 14 (29%), and with three to five surgeries for six (13%). For intended two-stage procedures (n = 39) an acceptable result was achieved with two surgeries for 26 patients (67%), three surgeries for eight (21%), and four surgeries for three (8%). Two other patients having two-stage surgery required seven surgeries to achieve an acceptable result. Complication rates are summarized in the Table. The complication rates for GMS 10 patients were similar (27% and 33%, p = 0.28) for one- and two-stage repairs, respectively. GMS 11 patients having a one-stage repair had a significantly higher complication rate (69%) than those having a two-stage repair (29%) (p = 0.04). GMS 12 patients had the highest complication rate with a one-stage repair (80%) compared with a complication rate of 37% when a two-stage repair was used (p = 0.12).
  
  
  CONCLUSIONS
  Guidelines to help standardize the surgical approach to severe hypospadias are needed. Staged surgery for GMS 11 and 12 patients may result in a lower complication rate but may not reduce the number of surgeries required for an acceptable result. Although further study is needed, the GMS score may be helpful for establishing such criteria.
authors.affiliation: Department of Urology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Jonathan
authors.initials: J
authors.lastname: Huang
authors.affiliation: Department of Biostatistics, Rollins School of Public Health, Emory University, Atlanta, GA, USA.
authors.forename: Lael
authors.initials: L
authors.lastname: Rayfield
authors.affiliation: Department of Pediatric Urology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Bruce
authors.initials: B
authors.lastname: Broecker
authors.affiliation: Department of Pediatric Urology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Cerwinka
authors.affiliation: Department of Pediatric Urology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Kirsch
authors.affiliation: Department of Pediatric Urology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Hal
authors.initials: H
authors.lastname: Scherz
authors.affiliation: Department of Pediatric Urology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA.
authors.forename: Edwin
authors.initials: E
authors.lastname: Smith
authors.affiliation: Department of Pediatric Urology, Emory University School of Medicine and Children's Healthcare of Atlanta, Atlanta, GA, USA. Electronic address: jmelmoremd@gmail.com.
authors.forename: James
authors.initials: J
authors.lastname: Elmore
mesh_terms: D000066491:Clinical Decision-Making; D016208:Databases, Factual; D006801:Humans; D007021:Hypospadias / Q000601:surgery*; D007223:Infant; D008297:Male; D018579:Patient Selection; D011183:Postoperative Complications / Q000453:epidemiology*; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: Complications; GMS; Hypospadias; Proximal