Snodgrass repair for distal hypospadias: a review of 75 cases

Abstract

Background/aim In 1994, Warren Snodgrass described his technique of tubularized incised plate urethroplasty, which is a relatively straightforward one-stage procedure. It has become the standard technique used by many urologists for distal hypospadias correction. We review our cases to find out whether there was any difference in the rate of urethrocutaneous fistula after the use of singleversus double-layer tubularization, the use of thick versus thin dorsal prepuce subcutaneous flap (DPF), the use of DPF versus the ventral dartos flap for repair cover, and also to find out whether the extension of the urethral plate incision till the neomeatus was associated with an increased rate of meatal stenosis.
Patients and methods We reviewed the operative notes and the out-patient files of all patients who underwent Snodgrass repair for distal hypospadias, over a period of 8 years. Follow-up extended from 2 to 24 months postoperatively. The variables addressed were as follows: the age during repair, the type of hypospadias, the tubularization technique, whether it was a single layer or with an additional reinforcing, second layer, the cover flap (dorsal prepuce subcutaneous vs. ventral local dartos fascia), the thickness of the dorsal flap when used (thin vs. thick), and the distal limit of the plate incision, whether including the site of the neomeatus or not. The complications addressed were the occurrence of urethrocutaneous fistula and meatal stenosis.
Results The study included 75 cases. Twenty-one (28%) boys operated were below 6 months, 17 (23%) between 6 and 12 months, and 37 (49%) above 1-year of age. A single suture-line tubularization was used in 17 (23%) and a reinforcing second layer was added in 58 (77%) patients [urethrocutaneous fistulae occurred in two (11.8%) and five (8.8%) patients, respectively]. The second layer flap was the dorsal subcutaneous prepuce in 63 (84%), thin in 16 (25%), and thick in 47 (75%) patients [urethrocutaneous fistulae occurred in two (12.5%) and four (8.5%) patients, respectively]. The ventral local dartos flap was used in 12 (16%) cases (all were already circumcised) [the fistula occurred in one (8%) patient]. The neomeatus site was included in the urethral plate incision in 45 patients, and not included in 30 [meatal stenosis occurred in eight (18%) and two (7%) patients, respectively].
Conclusions In Snodgrass repair of distal hypospadias, tubularization in two layers, together with proper harvesting of the thick DPF, decrease the fistula rate. Extending the plate incision to the neomeatus site is a predisposing factor for meatal stenosis.

Keywords: hypospadias, Snodgrass, tubularized incised plate, urethroplasty