An awardee’s
reflection

In April 2024, I had the distinct honour of being awarded the Saleem Khwaja Memorial Travelling Fellowship, which gave me the unique opportunity to visit the Hypospadias Surgical Centre in Texas, USA. My selection of this centre was deliberate, driven by the high prevalence of hypospadias in paediatric urology and the varying outcomes observed in patients. Dr Warren Snodgrass and Dr Nicol Bush, both internationally renowned for their specialisation in this field, have made significant contributions to hypospadias surgery, particularly with their extensive experience in distal, proximal and complex redo operations. Their numerous publications in peer-reviewed journals attest to their expertise and pioneering work. 

I was fortunate to stay with Janeth, the scrub technician, who welcomed me into her home as part of her family. The days were spent in the theatre and, throughout each case, we discussed the rationale behind the steps taken. The entire team, including Dr Bush and Dr Snodgrass, welcomed me, making the experience both highly informative and pleasant. 

The primary objective of my fellowship was to gain a deeper understanding of the surgical techniques and protocols employed by Dr Snodgrass and Dr Bush, focusing on their innovative procedures. Dr Snodgrass, who popularized the tubularized incised plate (TIP) procedure for distal hypospadias repair 30 years ago, recently with Dr Bush introduced the straighten and close (STAC) technique, which he developed as an alternative to the straighten and graft method. My goal was to observe the different stages of the STAC procedure, understand its indications, and learn how these surgeons decide when to employ each technique. During my two-week visit, I was immersed in the daily workings of the Hypospadias Surgical Centre, observing 21 hypospadias repairs and other procedures such as meatotomy and orchidopexy. This provided a comprehensive view of the methodologies employed by Dr Snodgrass and Dr Bush, on which I have reflected here.  

• Indications for procedures. In the operating theatre, the degree of ventral curvature, among other measurements, was obtained and recorded. The ventral curvature measured intraoperatively guided the choice between TIP and STAC. Mild curvature is managed with TIP, while significant curvature requires STAC. This preoperative assessment is crucial for determining the most appropriate surgical intervention and achieving the best outcomes for the patient. 

• Intraoperative documentation. Each case was meticulously documented with preoperative and postoperative photographs, facilitating objective assessment and improvement of techniques. This process ensures a comprehensive understanding of each case, allowing for continuous refinement and enhancement of surgical methods.

• Systematic approach to complex cases. One of the most informative aspects of my visit was observing how the surgeons systematically address complex cases. Their methodical approach ensures consistency in outcomes and reduces complications. This includes careful patient setup, strategic use of sutures and thoughtful selection of dressings. This systematic approach not only enhances surgical outcomes but also improves the overall patient experience by simplifying postoperative care.

• Postoperative care. Patient and parent education was in-depth, enabling them to remove dressings and catheters themselves. They maintained close follow-up as early as two weeks post-operation and considered the use of manuka honey topically. This proactive approach ensures that patients receive optimal care and support throughout their recovery process. Certain cases would be considered for hyperbaric oxygenation therapy, such as redo operation patients. One day, I had the opportunity to visit the department with Dr Davis, an anaesthesiologist consultant who supervises the treatment of HBOT in the centre. It was fascinating to see their setup and how patients of all ages use this facility. 

• Teamwork and patient care. The collaborative environment at the Hypospadias Surgical Centre was particularly impressive. Each team member understands their role, ensuring optimal patient safety and care. For instance, if a high degree of curvature is found intraoperatively, the surgeons immediately communicate with the team to adjust the procedure plan. Senior nurses are trained to explain the implications to parents, including the need for a staged procedure. This seamless teamwork is essential for maintaining high standards of care and ensuring the best possible outcomes for patients.

• Parental involvement and education. A noteworthy aspect of the centre’s approach is the involvement of parents in the treatment process. The clinic manager likened this to ‘coaching’ parents and patients to mentally prepare them for each stage of the operation and set realistic expectations. This proactive communication helps in managing anxiety and ensures parents are well informed about their child’s care. By actively involving parents, the centre fosters a supportive environment that enhances the overall treatment experience for patients and their families. 

• Weekly staff meetings. The staff meets weekly to review upcoming cases and plan accordingly. This meeting serves as a platform to raise concerns and discuss any issues, ensuring that all team members are aligned and prepared. This level of preparation and communication is crucial for maintaining high standards of patient care. These meetings also provide an opportunity for continuous learning and improvement, allowing the team to stay updated on the latest developments and best practices in hypospadias surgery. 

• Educational opportunities. Although Dr Snodgrass and Dr Bush do not currently have trainees, they are dedicated to teaching visitors and sharing their knowledge. They have an extensive collection of videos online, showcasing various cases and providing lectures on surgical techniques. This emphasis on education and knowledge dissemination aligns with my interest in teaching and contributes significantly to the broader medical community. By sharing their expertise, they are helping to advance the field of hypospadias surgery and improve patient outcomes worldwide. 

The fellowship has provided me with invaluable insights into advanced hypospadias surgery techniques and clinic management. I have taken important lessons to my practice, such as careful measurements intra-operatively, particularly the ventral curvature as a guide in the surgical procedure. The careful documentation of preoperative and postoperative findings is something I will start implementing in my daily practice. The detailed documentation will help me better understand the variations and outcomes from each procedure. It was not only the technical aspects of each procedure and each step but also the setup. Dr Snodgrass and Dr Bush were very inspiring for their work but also for their eagerness to help other centres and surgeons improve their practice through YouTube videos, publications and workshops. 

The Saleem Khwaja Memorial Fellowship has been a transformative experience, enhancing my surgical skills and expanding my understanding of hypospadias treatment. Observing the practices at the Hypospadias Surgical Centre has provided me with new perspectives on patient care, surgical innovation and the importance of teamwork. The centre’s dedication to advancing the field and sharing their knowledge is inspiring and has reinforced my commitment to excellence in paediatric urology. This fellowship has not only improved my technical abilities but also enriched my approach to patient care and education. 

Since the fellowship, I have presented my learning at the Scottish Society of Paediatric Surgery and in my department. Sharing my insights among fellow paediatric urologists will also help others considering adopting these practices. I am eager to apply these
insights to my practice, continually improving outcomes for my patients and contributing to the field of paediatric urology. 

Through continuous learning and collaboration, I hope to advance the field and ensure the best possible care for my patients.

For more information on establishing memorial funding opportunities, please email the Royal College of Surgeons of Edinburgh Development Office at development@rcsed.ac.uk.