Thank you for your interest in our study.

We totally agree with you and it is already mentioned in the article that intr-operative artificial erection test is the only reliable method to assess the severity of chordee.

It is correct that we have encountered patients with different grades of Hypospadias (including glanular hypospadias) with severe chordee that had Ano-Scrotal Distance (ASD) of 3 cm. However, all patients of grade III and IV with ASD< 2cm had severe chordee that required division of the urethral plate, excision of the outer longitudinal layer of Tunica vaginalis (TALE) or some sort of corporotomies and grafting or Tunica vaginalis flap.

In another words, ASD < 2cm is a helpful marker. However, ASD > 2cm does not exclude severe chordee. This is understandable as hypospadias is a very wide spectrum.

The paper is dealing with the relation of ASD and the severity of chordee and not with the management of severe chordee. There are several approaches of how to handle severe chordee and each surgeon uses the technique that works best in his hand with less complications. Glanular hypospadias with severe chordee is a very challenging group of patients (even more difficult than proximal or perineal with severe chordee). We have moved away from 2 stage approach for those particular group of patients with glanular hypospadias and severe chordee as the outcome was not satisfactory and complication rate was high.

All patients with perineal hypospadias had severe chordee and had staged repair.

All patients with distal or proximal hypospadias and severe chordee had staged repair.

Only 2 patients with glanular hypospadias and severe chordee had staged repair and they had complications and therefore we stopped performing staged repair for glanular hypospadias and severe chordee and the approach we use nowadays is as shown in Fig.2 in the study.

The number of patients with severe chordee who had division of the urethral plate are: 2 glanular + 9 distal + 25 proximal + 102 perineal = total 138 patients.

The take home message from the study is to measure the ASD during the consultation in the outpatient clinic. If the ASD is ≤ 2,0 cm (even in glanular hypospadias), the surgeon may inform the parents that the child is likely to have severe curvature and he may need two stage repair and complication rate could be higher than expected. However, the severity of chordee must be confirmed with erection test under anaesthesia.