The pioneering work of this world-renowned pediatric urologist has benefited legions of children 
  

PHILADELPHIA—Pediatric urologist Howard M. Snyder III has pioneered treatment for complex urinary tract and urogenital anomalies. He developed and taught
one-step hypospadias repair to generations of students, and made progress in diagnosing and managing patients with undescended testicles. Yet, the 63-year-old professor and éminence grise at the University of Pennsylvania School of Medicine here is still keen to learn new skills inside and outside the operating room.
 
For example, when he was called to active duty with his Army Medical Corps reserve unit during Operation Iraqi Freedom in 2003, Dr. Snyder jumped at the chance to serve. “We were going to do humanitarian surgery, but we also had to learn how to shoot M16 rifles and 9-mm pis-tols, perform convoy duty, and don gas masks in nine seconds flat,” he recalled in an exclusive interview with Renal & Urology News. “We had so much esprit de corps; we were ready to go.”
 
About a week before the unit’s fly date, however, the Army decided it didn’t need so much medical assistance and cancelled its deployment to Nasiriyah in southern Iraq. Shortly thereafter, Dr. Snyder and most of his 530-person unit were sent home. “Our relatives were probably somewhat relieved,” Dr. Snyder says, “but quite honestly, we were disappointed.”
 
Of course, Dr. Snyder has always enjoyed a challenge. After graduating from Harvard Medical School in 1969, he was initially trained as a general surgeon, but he didn’t hesitate to shift gears when he saw a chance to make a real contribution. During a two-year residency in pediatric general surgery at Boston Children’s Hospital, Dr. Snyder spotted a void. “About a third of the operations I did were major urologic reconstructive cases,” he relates. As he tried to figure out how to help his young patients, he would occasionally consult with senior pediatric surgeons, some of whom had world-class reputations. “I’d say, ‘How the devil am I supposed to fix this?’ and they’d say, ‘Well, you might try this, or you could try that,’ and I realized that they didn’t know what to do, either!”
 
That experience convinced Dr. Snyder to go into what was then a largely uncharted field—pediatric urology. After working for a year at two hospitals in England—“the only place where people were doing serious training in pediatric urology”—he returned home only to find that he couldn’t get a job. “In the United States; you have to be a board-certified urologist before you can perform children’s urology,” he explains. “So I went to an AUA [American Urological Association] meeting and approached the chiefs of urology at Massachusetts General and The Brigham Hospital, told them my predicament and said I needed to get my boards in urology. Both of them immediately said, ‘When would you like to start?’”
 
Dr. Snyder went to The Brigham Hospital, and eventually was triply board-certified in adult general surgery, pediatric general surgery, and urology. He arrived at the Children’s Hospital of Philadelphia (CHOP) in 1980 and, along with his friend and colleague, the late John Duckett, MD, set up one of the country’s earliest pediatric urology training programs. Now in his 26th year at CHOP, he says that program has educated “more pediatric urologists than anyplace else in the world.”
 
Undescended testicles
 
Although Dr. Snyder has done re-search in many areas and treated patients with a wide range of con-ditions, he has devoted special attention to the fertility-damaging consequences of undescended testicles (UDT).
 
He first became interested in UDT in the mid-1980s. “UDT is caused by transient hormonal abnormalities during development that leaves one or both of the testes outside the scrotum,” he explains. Either way, the condition can damage fertility later
in life. To investigate the problem, Dr. Snyder and his colleagues biopsied thousands of UDTs, studied the tissue samples, and figured out how to grade the severity of each pa-tient’s pathology. “With UDT, one in three males will have an abnormal sperm count; that’s about three times greater than the incidence of abnormal sperm count in males without UDT,” he says.
 
To help these patients live normal lives, Dr. Snyder’s group set up a program where boys with UDT return to CHOP at age 18 when they’ve achieved mature sperm production and undergo a fertility evaluation. Although there is still “room for improvement” in designing optimal hormonal regimens, Dr. Snyder says the data already show that such treatment can significantly improve long-term fertility. “We think,” he says, “that this will be an exciting aspect of care for these kids.”
 
Dr. Snyder notes that this kind of evaluation and treatment is not widely offered. “Many physicians still don’t understand the ramifications of UDT,” he says. Because most pediatricians don’t know that there’s a fertility issue during adulthood they just send the child to a surgeon who can move the testicle to its proper place, or, as Dr. Snyder says, “put the eight ball in the corner pocket.”
 
Breakthrough therapy
 
Dr. Snyder has also maintained a strong interest in treating hypospadias, a birth defect in which a boy’s urethra opens on the underside of the penis instead of at the end. The condition afflicts 1% of males. In severe cases, hypospadias can hinder or even preclude normal sexual and procreative function later in life. Unlike some pediatric urologists, Dr. Snyder strongly favors one-stage hypospadias repairs over those requiring two or more separate procedures. Although he concedes that there are “honest controversies” about this issue, he stands by his preference. “The approaches we’ve developed here at CHOP are well-respected enough that I’ve taught courses in hypospadias surgery all over the world, including Japan, China, and India,” he says, noting that the complication rates seen in two- and three-stage repair operations are no lower than those found with the single-stage procedures he teaches and performs.
“I have not done a staged operation for hypospadias in a primary case in 25 years,” he says. “If you really understand the anatomy and the techniques—some of which are pretty sophisticated—you won’t get excess bleeding and you will have excellent healing and a low complication rate.”
 
Urologic conditions spread
 
Dr. Snyder says hypospadias repair and UDT are among the issues that are likely to become even more important in the future because they’re part of a larger group of urologic conditions that seems to be on the rise. “We used to think hypospadias affected about 1 in 300 live births, and now it seems to affect about 1 in 100; at the same time the incidence of UTD has doubled, from 1% to 2% of males,” Dr. Snyder says. “There has also been a drop in adult male fertility and a rise in testicular malignancy in adult men.”
 
Dr. Snyder believes that manmade chemicals may be at the root of the problem. “I am a consultant with a group that’s been looking into the concept of man-made chemicals having hormonal effects,” he says. “A lot of them are contained in pesticides, fertilizers, and plastics. This is an area where there’s lots of controversy,” he adds, “but I’m convinced that these chemicals are to blame.”
 
While a number of urologic problems may be growing, progress also is being made toward solving them. At this point, Dr. Snyder thinks that minimally invasive surgery and tissue engineering are among the most  promising developments.
 
Although he only performs traditional open surgery, Dr. Snyder is a big fan of laparoscopy and robotic surgery for some pediatric patients. “We want to lessen the amount of suffering we put people through,” he says, “and the minimally invasive approach, whether you’re using a laparoscope or the robotic technique, enables you to create a lot less muscular discomfort. What mostly causes discomfort after any kind of surgical procedure is what you must do to gain access,” he explains. “What we do on the inside doesn’t necessarily cause trouble, but making a big excavation through someone’s abdominal wall in order to get to the problem sure does hurt!”
 
It was during a trip to Detroit several years ago that Dr. Snyder saw how effective minimally invasive surgery could be. While there, he had the chance to watch surgeon Mani Menon, MD, of the Vattikuti Urology Institute at Henry Ford Hospital, perform a robotic radical prostatectomy. “When I saw how effectively it worked and what you could do with the robotic control arms, I came back here and said to my partners, ‘Guys, I’ve
seen tomorrow.’”
 
Although Dr. Snyder was instrumental in bringing robotic surgery to CHOP, he cautions that it is not appropriate for every pediatric patient. “I think people sometimes over-apply the use of minimally invasive techniques in infancy,” he says. “In very small children everything is measured in millimeters, and the amount of muscular discomfort we create in a baby or toddler is small.” The biggest advantage of minimally invasive surgery is seen in older children, such as a seven-year-old or a 15-year-old who needs to have
a kidney removed. In these cases, he says, “you can certainly lessen their suffering with minimally invasive surgery.”
 
Tissue engineering
 
Another area of hope, in Dr. Snyder’s view, lies in tissue engineering. “Growing tissues in a culture medium so they can be used by the human body is a wonderful concept,” he says. “Back in the 1980s we began working on growing uro-epithelium. But we’ve gone way beyond that today.” Dr. Snyder singles out Anthony Atala, MD, director of regenerative medicine at the Wake Forest University School of Medicine in Winston-Salem, N.C., for special kudos. Dr. Atala and his colleagues have already cultured kidney-like cells in the lab and injected the resulting tissue into animals, where they have been able form kidney structures and produce a urine-like fluid.
 
“If you look at how many patients have renal failure in old age—and if we could inject new kidney tissue into their old kidneys and have it hook up with their plumbing and restore normal renal function—this would be a tremendous contribution,” he says, his voice rising. Of course, Dr. Snyder hastens to add, such revolutionary developments do not spring fully formed into existence overnight. “But if you ask me whether I think things like this will be available 20 years from now,” he concludes, “you bet I do.”