No Margin for Error is not only a memoir of the ‘pound for pound’ most influential hypospadiologist of the 21st century, but also a blueprint to self-examination and improvement. It’s an essential read for any urologist starting their career to understand the importance of recognising technical error and taking action to correct it.
Warren Snodgrass has demonstrated through his life’s work how he implemented the three Ps: Prospective data collection, Periodic review of results, and Practice changes to improve outcomes. This process, however simple it may sound, involves the painful act of looking oneself in the mirror and admitting complications happen because of technical error. The reward of improved outcomes after technical changes is surely worth it. The book has three main sections following the three procedures the author is well known for: the TIP repair, the STAG repair and the STAC repair. The book has many pictures that capture significant moments in hypospadias history like the first multicentre presentation of the famous TIP repair.
“By the age of 50, every man has the face he deserves.” This saying, attributed to George Orwell, suggests that a person’s face reveals their actions, and attitudes over the years with the inevitability of facing the consequences of one’s life choices. Dr Snodgrass’s is immediately recognised at international meetings as an authority on best practice to repair hypospadias. Perhaps it’s his truth-seeking research that earned him this status. He may be the only surgeon who publicly admitted and published a 100% complication rate doing a procedure (hypospadias flap repairs) but as a result changed his practice to graft repair with greater success (Snodgrass W, Bush N. Primary hypospadias repair techniques: A review of the evidence. Urology Annals 2016;8(4):403).
The book also explores emotional struggles. Whether it’s a walk barefoot on Galveston beach after a sleepless night or the melancholy of the last day in his university career, the book illustrates a very personal part of the author’s journey. It also discusses emotional stories from parents and older men who suffered because of failed hypospadias surgery.
The author raises a question about why hypospadias surgeons would not follow data and best available evidence for a better result. The answer to that question perhaps lies in the Navaho proverb “you cannot wake a man who’s pretending to be asleep”. The status quo of accepting high complications offers the comfort of saying there’s something inherently wrong with hypospadias as a complex pathology to explain poor outcomes rather than seeing room for technical improvement.
The book is an invitation to be self-critical to improve results. At the heart of this journey are young children and their parents who only want their boys to grow up to be normal men without the suffering of repeat genital surgery.
