Snodgrass 2005 - BJUI - Hypospadias Repair

Summary

The Snodgrass technique is a surgical method for correcting hypospadias, a congenital condition where the urethral opening is on the underside of the penis rather than at the tip. This article, published in BJU International in 2005, was written by Dr. Warren T. Snodgrass, the urologist who pioneered the technique in the 1990s.

Hypospadias can be corrected by various surgical techniques including tubularization of the urethral plate, skin flaps, and grafts. The Snodgrass technique involves incising and tubularizing the existing urethral plate to create a neourethra. This technique has gained popularity over the last decade as it simplifies surgical decision-making, has a lower complication rate, and provides better cosmetic outcomes compared to other techniques.

Patient selection: The Snodgrass technique can be used for most cases of midshaft, distal and even some proximal hypospadias. It is contraindicated if the urethral plate was previously excised or is scarred. The surgery is typically performed around 3-18 months of age. Preoperative hormones may be given if the glans is small.

Surgical technique: The patient is prepped and a traction suture is placed in the glans. After degloving the penis, artificial erection tests for curvature. A dorsal plication suture can correct mild curvature. Longitudinal incisions are made to mobilize the glanular wings from the urethral plate. The key step is the midline incision through the entire urethral plate from the meatus to the tip, extending down to the corpora cavernosa. This relaxes the plate for tubularization. A 6F stent is passed into the bladder and secured to the glans suture. The urethral plate is then tubularized over the stent using a two-layer running subepithelial closure with 7-0 polyglactin suture. The first stitch defines the oval neomeatus shape.

After tubularization, a dartos flap is rotated to cover the neourethra for additional vascularization and fistula prevention. Glansplasty approximates the glanular wings in two layers with polyglactin sutures. The skin is then closed, either via circumcision or foreskin reconstruction as desired. Post-op dressing, stent and antibiotics are prescribed.

For proximal hypospadias, the urethral plate is preserved if possible while correcting curvature. The plate's health is assessed by test incision before committing to tubularization. A two-layer plate closure and spongiosum coverage help prevent fistulas. Megameatus variants may require special considerations.

Outcomes: Fistula rates of 2% are reported for distal repairs. Proximal repairs initially had higher fistula rates, but modifications improved outcomes. Meatal stenosis is rare with proper surgical technique. Cosmetic results are excellent due to the slit-like neomeatus shape. The Snodgrass technique simplifies hypospadias surgery and provides reliable outcomes across a range of defects. It has become a mainstream approach for primary and redo hypospadias repairs when the urethral plate is intact.

In summary, this key article outlines the Snodgrass technique for tubularized incised plate urethroplasty. By incising and tubularizing the urethral plate, neourethra construction is simplified compared to earlier flap and graft techniques. Careful patient selection and surgical detail are needed to optimize outcomes. The Snodgrass technique now represents a versatile, mainstream approach for correcting various forms of hypospadias.