The simple answer to the question these authors [1] pose is; not reliably. They report a vertical slit meatus was achieved in 75% of patients with a deeply grooved urethral plate with or with no V-incision. Therefore, the test of the V-incision modification was in those patients with a moderate or shallow groove in the plate, and in the experience of the authors the V-incision in these cases increased the likelihood from 13% to 44% that a slit meatus would result. However, fewer than half the patients most at risk for an undesirable appearance of the meatus benefited from V-incision.

The V-incision was developed to improve the Mathieu procedure, and as the authors note, proponents have claimed complete success in creating a vertical slit meatus. No clear explanation is offered for the disparity between these reports and the authors’ results, as the length of the neourethra would not be expected to affect the appearance of the meatus. Furthermore, the authors never defined their patient population, but imply they had proximal hypospadias. As some boys with proximal hypospadias have a smaller glans, did the V-incision leave less ventral glans to approximate below the neomeatus?

The alternative approach to improve meatal appearance is to ‘hinge’ a moderate or shallow groove in the urethral plate by a dorsal midline incision. As the authors admit, TIP is considered most likely to create the desired vertical slit meatus. Now that the desired outcome potentially can be achieved, there is greater pressure on the surgeon to do so. Unfortunately, nearly all reports, including mine, have simply stated the operating surgeon’s opinion of the outcome with no objective assessment. The authors used postoperative photographs to judge the meatus, but outcomes apparently were determined by the surgeons, rather than by independent observers, as used by Ververidis et al. (reference 12 in the article). Including photographs of normal boys after circumcision would further validate the comparison of hypospadias outcomes to the desired ideal.

The authors state patients and parents ‘expect’ a circumcised penis after hypospadias repair. In many cultures a circumcised penis is not preferred, with patients and families agreeing to this result because nothing else is offered. With increasing emphasis on cosmetic outcomes, surgeons should consider foreskin reconstruction for all such patients, unless severe ventral curvature and/or a paucity of shaft skin mandates circumcision. Onlay flaps limit foreskin reconstruction, which is another reason that TIP might be a better option, even for proximal hypospadias.