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Expert classification of hypospadias: evaluation of agreement among current standardized reporting methods
Jin Kyu Kim, MD1, Nicolas Fernandez, MD, PhD2, Priyank Yadav, MD1, Mandy Rickard, MN, NP1, Jan Michael Silangcruz, MD3, Armando J. Lorenzo, MD, MSc1, Michael E. Chua, MD, MASc1.
1The Hospital for Sick Children, Toronto, ON, Canada, 2Seattle Children's Hospital, Seattle, WA, USA, 3St. Luke's Medical Center, Quezon City, Philippines.

BACKGROUND: The outcomes of hypospadias repair have been strongly associated with the severity of the disease, with more proximal hypospadias requiring more extensive reconstruction compared to distal ones. Due to the subjective nature of hypospadias classification, there have been efforts at developing a classification system that can achieve consistent agreement in clinically meaningful characteristics of hypospadias that may affect outcomes. Hence, we evaluate the inter-rater agreements of Glans-Urethral Meatus-Shaft (GMS) hypospadias score and Hypospadias Objective Penile Evaluation (HOPE) score.
METHODS: Photos of hypospadias in children taken in a standardized manner from the ventral side of the penis, with position of meatus and quality of urethral plate clearly visible, were collected from two separate institutions (Figure 1). Using the GMS and HOPE scores, three independent raters scored the hypospadias photos. Specifically for HOPE score, the penile torsion and curvature were not evaluated as this was difficult to accurately discern on a single photo.
RESULTS: A total of 528 photos were included for evaluation. For GMS scores, Fleiss' multi-rater kappa showed an agreement of: 0.745 (95% CI 0.711-0.778) for Glans-Urethral Plate, 0.869 (95% CI 0.839-0.898) for Meatus, and 0.745 (95% CI 0.715-0.774) for Shaft. For HOPE scores, the observed agreements were: 0.888 (95% CI 0.862-0.914) for position of meatus, 0.669 (95% CI 0.638-0.700) for shape of meatus, 0.730 (95% CI 0.696-0.765) for shape of glans, and 0.708 (95% CI 0.678-0.738) for shape of skin. The poorest agreement seen in shape of meatus is likely due to lack of quantitative classification method as HOPE scoring provides several example photos of what score an example hypospadias should have, with experts needing to classify based on their judgement of the provided example photos and their index patient. The best agreement was seen, in contrast, with position of meatus, which was easily discernable based in an objective manner on the example figure the authors had provided in their description of HOPE scores.
CONCLUSIONS:
There is an overall high agreement in evaluating hypospadias among experts when using GMS and HOPE scoring criteria. However, there is still room for improvement as only the position of meatus achieves nearly perfect agreement with kappa of >0.8 among experts for both GMS and HOPE. Improvements may be achieved by reducing the subjective nature of scoring and creating more objective means of scoring.


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