The lack of standardization of hypospadias repair revolves around varied understanding of chordee and lack of consensus among experts regarding choice of repair. The former contentious issue has been largely put to rest with the advent of urethral plate urethroplasty techniques. The development of this repair followed better clarity in understanding chordee and urethral plate.[1
] The major shift in this perception has been distinction between superficial skin tethering and true fibrous contracture as a contributor to chordee.[5
] Although chordee is present in 25-55% of all hypospadias, a sizable number are peroperatively correctable by penile degloving.[7
] Hence, urethral plate urethroplasty emerged as a potent option in majority of cases.[10
] However, this knowledge has not paved the way to standardized repair protocol because proponents of different techniques extended specific indications for their respective procedure to in all types of hypospadias.[8
There have been attempts in clearing this ambiguity by proposing algorithms.[11
] The algorithm presented in this study tows this line of standardizing the treatment protocol of hypospadias. In this protocol TIUP repair is indicated in all distal cases with no chordee and in those where chordee is resolved by penile degloving, and is in consonance with other authors.[11
] However, this algorithm deviates from some of the published protocol on two counts. First, dorsal plication is not exercised as an orthoplasty modality in cases with severe chordee where degloving does not suffice and secondly, TIUP is replaced by TPIF and Bracka's[23
] repair in proximal cases after formal chordee excision sacrificing urethral plate. We avoid dorsal plication even in older children and adults since it leads to shortening of the penis. The benefit of the algorithm lies in the fact that a surgeon needs to master only three techniques, which he or she can apply objectively in defined indications. Following this system, all types of hypospadias can be managed.
Our study revealed 60% (27 out of 45) had chordee, but true fibrous chordee was present only in 31.11% (14 out of 45) of cases and 13 had superficial skin tethering. Eighteen cases had no chordee. This objective preoperative categorization was feasible by following the algorithm proposed by us. Thirty one patients (68.89%) i.e., 18 without chordee and 13 cases with superficial skin tethering were repaired by Snodgrass repair. This technique could be executed in all coronal and distal hypospadias and 7 out of 12 mid penile hypospadias. The algorithm allowed us to take a preoperative decision in 13 cases of superficial skin tethering which resolved after skin take down allowing Snodgrass repair. None of the proximal and penoscrotal hypospadias allowed modified Snodgrass repair as there was significant chordee after degloving. This is in deviation from number of previous reports, where Snodgrass repair was used in proximal and penoscrotal cases.[8
] This was possible because these authors used dorsal plication in cases of severe chordee thereby preserving the urethral plate. But the need for judicious use of Snodgrass repair in proximal cases with severe chordee has been proposed by the pioneer of the technique himself.[8
] Snodgrass himself recommends staged repair in these cases where a possibility of recurrent curvature and other complications is anticipated.[8
] There are even reports of combining the Snodgrass repair with Thiersch-Duplay technique in proximal cases. The former is used to reconstruct the glandular urethra and penile urethroplasty was done with the latter technique.[17
Out of the 31 cases where urethral plate was utilized, classical Snodgrass repair was possible in 21 cases and rest of the 10 patients had narrow urethral plate necessitating the modification proposed by us. This simple modification of recruiting little bit of shaft and glandular skin lateral to the plate made it possible to tubularize the incised urethral plate. This has extended the reach of this novel technique and obviated the need of more demanding onlay preputial island flap repair.[11
] Most of the cases (8 out of 10) requiring the modified Snodgrass repair were >15 years of age. These cases needed urethroplasty over a 12 or 14 F catheter. Hence, we feel "narrow" urethral plate was more relative than absolute, depending upon the size of the catheter over which we need to tubularize the urethral plate. We face such situations since a sizable number of our primary hypospadias patients are adolescent and adults.
Our fistula rate with Snodgrass repair and its modification was 9.67% (3 out of 31) which is within the limits of the reported fistula rates by different authors.[8
] A single layer closure without a dartos flap simplifies the technique further without compromising the fistula rate. This is because we transpose the skin ventrally and close the skin on the dorsal aspect, keeping the skin suture away from the urethroplasty. We accept that because of this a median raphe could not be made and led to dog ears. But we feel that this cosmetic shortcoming in face of a simplistic repair with minimal fistula rate, is acceptable. These ventral skin redundancies and dog ear can easily be corrected at a later stage to improve the aesthetics when functional end point has been reached.