Undescended testicles

Although Dr. Snyder has done research in many areas and treated patients with a wide range of conditions, 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 patient’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.

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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.”