This document describes a technique called the "split and roll technique" for correcting severe chordee (abnormal curvature of the penis) associated with hypospadias. The technique involves:
1) Splitting the septum between the corpora cavernosa with a ventral midline incision to partially separate the corpora and facilitate rotation.
2) Placing nonabsorbable sutures from the dorsolateral aspect of one corpus across the midline to the other corpus. Tying the sutures rotates the corpora toward the dorsal midline, correcting the curvature.
3) This technique avoids incisions into the corporal substance and does not require grafts or cause penile shortening
Endoscopic Endonasal Transclival Approach to the Ventral BrainstemDr. Shahnawaz Alam
Endoscopic Endonasal Transclival Approach to the Ventral Brainstem: Anatomic Study of the Safe Entry Zones Combining Fiber Dissection Technique with 7 Tesla Magnetic Resonance Guided Neuronavigation
Endoscopic Endonasal Transclival Approach to the Ventral BrainstemDr. Shahnawaz Alam
Endoscopic Endonasal Transclival Approach to the Ventral Brainstem: Anatomic Study of the Safe Entry Zones Combining Fiber Dissection Technique with 7 Tesla Magnetic Resonance Guided Neuronavigation
Minimally invasive spine surgeries (MISS) since its inception around 15 years ago has undergone rigorous changes with ever evolving technologies. Minimally invasive spine surgeries with “percutaneous” and “tubular” approaches is based on novel concept of minimizing collateral soft tissue damage, while achieving surgical goal in various spinal pathologies. MISS has been applied to simple spinal procedures of discectomy, decompression and fusion to even complex surgeries like deformity correction. MISS vis a vis “conventional open techniques” has benefits in terms of postoperative pain, concurrent tissue damage, disruption of spinal stabilizing structures, estimated blood loss, need of blood transfusion, length of hospital stay, surgical site infections, time to ambulation and functional recovery.
This presentation will give you a detailed knowledge about the various techniques that can be performed for imaging various aspects and diseases of TM Joint.
Management of Posterior Glenohumeral Instability with Large Humeral Head DefectPeter Millett MD
Traumatic posterior instability may occasionally cause a large osteochondral lesion when the anterior humeral head is compressed against the posterior glenoid rim. This is termed a reverse Hill–Sachs lesion. Such osteochondral defects may be very large in the case of chronic locked dislocations. Even in acute posterior disclocations, closed reduction may be difficult when the humeral head is locked posteriorly over the glenoid. In such cases closed or open reduction under general anesthesia with muscle relaxation may be necessary. In cases where the anterior humeral head defect is large, reconstruction may be necessary to maintain stability. Management must be tailored to the individual patient and depends on several factors, which include the size of the defect, the duration of the dislocation, the quality of the bone, the status of the articular cartilage, and the patient’s overall health. For more shoulder surgery and instability studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Treatment of displaced midshaft clavicle fracture with locking compression plate provides better biomechanical stability, good fracture union rates, high post-operative constant score, early pain resolution, early return to activity, high patient satisfaction rates and excellent functional outcome. These benefits of plating overweigh complications when used in specific indications like displaced with or without comminuted middle third clavicle fracture (Robinson Type 2B1, 2B2).
Minimally invasive spine surgeries (MISS) since its inception around 15 years ago has undergone rigorous changes with ever evolving technologies. Minimally invasive spine surgeries with “percutaneous” and “tubular” approaches is based on novel concept of minimizing collateral soft tissue damage, while achieving surgical goal in various spinal pathologies. MISS has been applied to simple spinal procedures of discectomy, decompression and fusion to even complex surgeries like deformity correction. MISS vis a vis “conventional open techniques” has benefits in terms of postoperative pain, concurrent tissue damage, disruption of spinal stabilizing structures, estimated blood loss, need of blood transfusion, length of hospital stay, surgical site infections, time to ambulation and functional recovery.
This presentation will give you a detailed knowledge about the various techniques that can be performed for imaging various aspects and diseases of TM Joint.
Management of Posterior Glenohumeral Instability with Large Humeral Head DefectPeter Millett MD
Traumatic posterior instability may occasionally cause a large osteochondral lesion when the anterior humeral head is compressed against the posterior glenoid rim. This is termed a reverse Hill–Sachs lesion. Such osteochondral defects may be very large in the case of chronic locked dislocations. Even in acute posterior disclocations, closed reduction may be difficult when the humeral head is locked posteriorly over the glenoid. In such cases closed or open reduction under general anesthesia with muscle relaxation may be necessary. In cases where the anterior humeral head defect is large, reconstruction may be necessary to maintain stability. Management must be tailored to the individual patient and depends on several factors, which include the size of the defect, the duration of the dislocation, the quality of the bone, the status of the articular cartilage, and the patient’s overall health. For more shoulder surgery and instability studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
Treatment of displaced midshaft clavicle fracture with locking compression plate provides better biomechanical stability, good fracture union rates, high post-operative constant score, early pain resolution, early return to activity, high patient satisfaction rates and excellent functional outcome. These benefits of plating overweigh complications when used in specific indications like displaced with or without comminuted middle third clavicle fracture (Robinson Type 2B1, 2B2).
Presentation from Chatham Economic Development Corporation's annual Opportunity Chatham breakfast meeting. Includes Census tract data about incoming, housing, poverty, and more.
View the presentation from the EDC's February 7, 2013 Joint Boards Meeting. Learn about the development of a conceptual (*not* comprehensive) land use plan for Chatham County.
Split Pectorales Major and Teres Major Tendon Transfers for Reconstruction of...Peter Millett MD
Isolated ruptures of the subscapularis and anterosuperior rotator cuff lesions are encountered more rarely than supraspinatus or anteroposterior rotator cuff tears. In certain circumstances, reconstruction of the tendon may not be possible due to fatty degeneration and atrophy of the subscapularis muscle or poor tendon quality. Tendon transfer may represent the only surgical option for treatment. A pectoralis major tendon transfer is an acceptable salvage option for irreparable subscapularis tendon ruptures. Although limited functional goals may be expected in most cases, the majority of patients obtain a good pain relief, which improves their function below chest level. Addition of the teres major component to the transfer may be beneficial in cases where both the upper and lower portion of the subscapularis muscle is irreparable. For more shoulder surgery and rotator cuff studies, visit Dr. Millett, The Steadman Clinic, Vail Colorado http://drmillett.com/shoulder-studies
The esophageal hiatus is an elliptical opening in the diaphragmatic muscular portion. The crura of diaphragm originate from the anterior surface of the first four lumbar vertebrae on the right and L2–L3 on the left to insert anteriorly into the transverse ligament of the central portion of diaphragm.
Incarcerated infraumbilical incisional hernia: a surgical challengeDrKetanVagholkar
Incisional hernia continues to be the most challenging type of hernia. Variability in the anatomy and supervening
complications add to its complexity. Infraumbilical incisional hernias are usually due to gynecological operations.
This may range from a scar of tubal ligation procedure to a Pfannenstiel incision or an infraumbilical scar of caesarian
section. The sparse volume of strong anatomical structures in this region poses the biggest challenge during repair. A
54-year-old lady presented with a hernia arising from a scar of previous tubal ligation surgery. The hernia was
irreducible with a large mass of omentum in the hernial sac. Laparoscopy was difficult to perform in view of the
current state. Hence open surgery was performed. The technique used was creation of a preperitoneal space followed
by creation of space between external oblique aponeurosis and underlying muscle. A mesh as placed between the
muscular and aponeurotic layer. The post-operative course was uneventful with no recurrence. The anatomical basis
of placing the mesh between the muscular and aponeurotic layer or intermediate placement technique is discussed.
Creation of space below the aponeurotic level is pivotal in managing infraumbilical incisional hernia. Placing a mesh
at this layer below the aponeurosis ensures least complications with excellent result.
Colonic incarceration in an adult umbilical hernia: case report and review of...KETAN VAGHOLKAR
Umbilical hernia is one of the commonest ventral hernias constituting ten percent of all hernias. It affects obese individuals and has a high recurrence rate if repaired by suture techniques. Incarceration of the colon in an umbilical hernia is quite rare. A case of colonic incarceration in an umbilical hernia is presented to highlight the diagnostic and technical challenges in managing such a hernia. Contrast enhanced computerized tomography is essential to ascertain the contents. Open surgery is the main stay of treatment especially in such rare cases. A combined tissue and mesh repair provides excellent results.
Hydrocele of the Canal of Nuck (HCN) is a rare condition seen in adult females. Diagnosis of HCN poses a
great challenge to the attending surgeon. There are various variants of embryological abnormality of the
processes vaginalis manifesting in different forms. Understanding the embryological development of the
processes vaginalis and the gubernaculum in female is therefore essential for determining the best surgical
option for treating these rare cases.
The Hypospadias, Chordee, Orthoplasty and The Prepucial Hoodsemualkaira
Making the surgeons aware of the significance of penile chordee, need of optimal straightening of penile shaft (orthoplasty) and appropriate use of well-developed prepucial hood for re-construction of an ideal neo-urethral plate and a near normal neo-urethra by its tubularization and finally re-enforcement of the neo-urethra by prepucial dartos fascial flap to minimize post-operative morbidities.
The Hypospadias, Chordee, Orthoplasty and The Prepucial Hoodsemualkaira
Making the surgeons aware of the significance of
penile chordee, need of optimal straightening of penile shaft (orthoplasty) and appropriate use of well-developed prepucial hood
for re-construction of an ideal neo-urethral plate and a near normal
neo-urethra by its tubularization and finally re-enforcement of the
neo-urethra by prepucial dartos fascial flap to minimize post-operative morbidities.
Similar to Chordee correction by corporal rotation:The Split and Roll technique (20)
Autoría de Alvaro Hernandez Zambrano y tomado de:http://www.universidadcooperativa.org/
en consideración de la seriedad de su contenido y por tratarse de ser un documento de interés público.
Recomendações da OMS sobre cuidados maternos e neonatais para uma experiência pós-natal positiva.
Em consonância com os ODS – Objetivos do Desenvolvimento Sustentável e a Estratégia Global para a Saúde das Mulheres, Crianças e Adolescentes, e aplicando uma abordagem baseada nos direitos humanos, os esforços de cuidados pós-natais devem expandir-se para além da cobertura e da simples sobrevivência, de modo a incluir cuidados de qualidade.
Estas diretrizes visam melhorar a qualidade dos cuidados pós-natais essenciais e de rotina prestados às mulheres e aos recém-nascidos, com o objetivo final de melhorar a saúde e o bem-estar materno e neonatal.
Uma “experiência pós-natal positiva” é um resultado importante para todas as mulheres que dão à luz e para os seus recém-nascidos, estabelecendo as bases para a melhoria da saúde e do bem-estar a curto e longo prazo. Uma experiência pós-natal positiva é definida como aquela em que as mulheres, pessoas que gestam, os recém-nascidos, os casais, os pais, os cuidadores e as famílias recebem informação consistente, garantia e apoio de profissionais de saúde motivados; e onde um sistema de saúde flexível e com recursos reconheça as necessidades das mulheres e dos bebês e respeite o seu contexto cultural.
Estas diretrizes consolidadas apresentam algumas recomendações novas e já bem fundamentadas sobre cuidados pós-natais de rotina para mulheres e neonatos que recebem cuidados no pós-parto em unidades de saúde ou na comunidade, independentemente dos recursos disponíveis.
É fornecido um conjunto abrangente de recomendações para cuidados durante o período puerperal, com ênfase nos cuidados essenciais que todas as mulheres e recém-nascidos devem receber, e com a devida atenção à qualidade dos cuidados; isto é, a entrega e a experiência do cuidado recebido. Estas diretrizes atualizam e ampliam as recomendações da OMS de 2014 sobre cuidados pós-natais da mãe e do recém-nascido e complementam as atuais diretrizes da OMS sobre a gestão de complicações pós-natais.
O estabelecimento da amamentação e o manejo das principais intercorrências é contemplada.
Recomendamos muito.
Vamos discutir essas recomendações no nosso curso de pós-graduação em Aleitamento no Instituto Ciclos.
Esta publicação só está disponível em inglês até o momento.
Prof. Marcus Renato de Carvalho
www.agostodourado.com
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share - Lions, tigers, AI and health misinformation, oh my!.pptxTina Purnat
• Pitfalls and pivots needed to use AI effectively in public health
• Evidence-based strategies to address health misinformation effectively
• Building trust with communities online and offline
• Equipping health professionals to address questions, concerns and health misinformation
• Assessing risk and mitigating harm from adverse health narratives in communities, health workforce and health system
DISSERTATION on NEW DRUG DISCOVERY AND DEVELOPMENT STAGES OF DRUG DISCOVERYNEHA GUPTA
The process of drug discovery and development is a complex and multi-step endeavor aimed at bringing new pharmaceutical drugs to market. It begins with identifying and validating a biological target, such as a protein, gene, or RNA, that is associated with a disease. This step involves understanding the target's role in the disease and confirming that modulating it can have therapeutic effects. The next stage, hit identification, employs high-throughput screening (HTS) and other methods to find compounds that interact with the target. Computational techniques may also be used to identify potential hits from large compound libraries.
Following hit identification, the hits are optimized to improve their efficacy, selectivity, and pharmacokinetic properties, resulting in lead compounds. These leads undergo further refinement to enhance their potency, reduce toxicity, and improve drug-like characteristics, creating drug candidates suitable for preclinical testing. In the preclinical development phase, drug candidates are tested in vitro (in cell cultures) and in vivo (in animal models) to evaluate their safety, efficacy, pharmacokinetics, and pharmacodynamics. Toxicology studies are conducted to assess potential risks.
Before clinical trials can begin, an Investigational New Drug (IND) application must be submitted to regulatory authorities. This application includes data from preclinical studies and plans for clinical trials. Clinical development involves human trials in three phases: Phase I tests the drug's safety and dosage in a small group of healthy volunteers, Phase II assesses the drug's efficacy and side effects in a larger group of patients with the target disease, and Phase III confirms the drug's efficacy and monitors adverse reactions in a large population, often compared to existing treatments.
After successful clinical trials, a New Drug Application (NDA) is submitted to regulatory authorities for approval, including all data from preclinical and clinical studies, as well as proposed labeling and manufacturing information. Regulatory authorities then review the NDA to ensure the drug is safe, effective, and of high quality, potentially requiring additional studies. Finally, after a drug is approved and marketed, it undergoes post-marketing surveillance, which includes continuous monitoring for long-term safety and effectiveness, pharmacovigilance, and reporting of any adverse effects.
Local Advanced Lung Cancer: Artificial Intelligence, Synergetics, Complex Sys...Oleg Kshivets
Overall life span (LS) was 1671.7±1721.6 days and cumulative 5YS reached 62.4%, 10 years – 50.4%, 20 years – 44.6%. 94 LCP lived more than 5 years without cancer (LS=2958.6±1723.6 days), 22 – more than 10 years (LS=5571±1841.8 days). 67 LCP died because of LC (LS=471.9±344 days). AT significantly improved 5YS (68% vs. 53.7%) (P=0.028 by log-rank test). Cox modeling displayed that 5YS of LCP significantly depended on: N0-N12, T3-4, blood cell circuit, cell ratio factors (ratio between cancer cells-CC and blood cells subpopulations), LC cell dynamics, recalcification time, heparin tolerance, prothrombin index, protein, AT, procedure type (P=0.000-0.031). Neural networks, genetic algorithm selection and bootstrap simulation revealed relationships between 5YS and N0-12 (rank=1), thrombocytes/CC (rank=2), segmented neutrophils/CC (3), eosinophils/CC (4), erythrocytes/CC (5), healthy cells/CC (6), lymphocytes/CC (7), stick neutrophils/CC (8), leucocytes/CC (9), monocytes/CC (10). Correct prediction of 5YS was 100% by neural networks computing (error=0.000; area under ROC curve=1.0).
These simplified slides by Dr. Sidra Arshad present an overview of the non-respiratory functions of the respiratory tract.
Learning objectives:
1. Enlist the non-respiratory functions of the respiratory tract
2. Briefly explain how these functions are carried out
3. Discuss the significance of dead space
4. Differentiate between minute ventilation and alveolar ventilation
5. Describe the cough and sneeze reflexes
Study Resources:
1. Chapter 39, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 34, Ganong’s Review of Medical Physiology, 26th edition
3. Chapter 17, Human Physiology by Lauralee Sherwood, 9th edition
4. Non-respiratory functions of the lungs https://academic.oup.com/bjaed/article/13/3/98/278874
Knee anatomy and clinical tests 2024.pdfvimalpl1234
This includes all relevant anatomy and clinical tests compiled from standard textbooks, Campbell,netter etc..It is comprehensive and best suited for orthopaedicians and orthopaedic residents.
2. 1153
CHORDEE CORRECTION BY CORPORAL ROTATION
is identified and incised using a microsurgical knife. The case artificial erection revealed a straight phallus intraoper-
incision partially separates the 2 corpora cavernosa (fig. 1, atively.
B). This incision extends along the length of the intracorporal
septum from the glans to the meatus. It is deepest in the area
DISCUSSION
of maximum ventral curvature. Care must be taken to avoid
accidental entry into either corporal body. The septum is a Various techniques are available to the reconstructive sur-
thin structure and dissection must proceed carefully or the geon for correcting chordee associated with hypospadias. It is
corpora will be entered and bleeding will be excessive. Pre- clear that in the majority of boys with hypospadias releasing
cise placement of the incision is facilitated by rolling the the ventral skin and its associated dartos fascia straightens
the phallus.1 Some patients have persistent chordee even
corpora away from the ventral midline and instilling inject-
able saline into the corpora using the artificial erection tech- after the skin is released, and the dysgenetic tissue on the
nique to aid in identifying the appropriate plane. It is not ventral aspect of the corpora cavernosa adjacent to the cor-
necessary to separate the corpora cavernosa completely, but pus spongiosum and urethral plate is dissected. Mollard and
only to incise the septum partially. Splitting the septum Castagnola suggested that excising the fibrous tissue under
facilitates corporal rotation, which is done subsequently to the urethral plate almost invariably results in straightening
this chordee7 but this has not been my experience. Even
straighten the penis.
Repeat artificial erection testing at this point reveals per- when the urethral plate has been completely divided and
sistent ventral curvature due to corporal disproportion and dissection is performed on the ventrum to clean the tunica
points out the area of maximum deformity. Access to the albuginea of the corpora cavernosa, chordee persists in some
dorsal aspect of the corpora cavernosa is achieved by dissect- patients. The persistent curvature appears to be due to cor-
ing Buck’s fascia with its encased neurovascular bundles poral disproportion.
starting at the ventrolateral aspect of the corpora cavernosa Perhaps the most widely used techniques to correct this
problem are variations of the Nesbit plication.2, 8, 9 Plicating
on each side and proceeding toward the dorsum (fig. 1, C).
This dissection is performed with fine tenotomy scissors and the dorsum of the corpora obviously shortens that aspect of
it mobilizes the neurovascular bundles from the glans dis- the penis to correct curvature. In most patients shortening is
tally to an appropriate position proximally on the penile not significant enough to prevent using the technique. Some
shaft. After Buck’s fascia and the neurovascular bundles are surgeons incise directly through Buck’s fascia to place the
plicating sutures.8 This approach risks inadvertent injury to
mobilized they are elevated with vessel loops to allow easy
access to the dorsum (fig. 1, D). Each corpus cavernosum is the neurovascular bundles, which are located on either side
then rotated toward the dorsal midline by positioning a of the dorsal midline with branches ramifying distally
transverse nonabsorbable suture on the dorsal aspect of 1 around the corpora cavernosa to the ventral side of the phal-
lus.10 When the corpora cavernosa are plicated, Buck’s fascia
corpus across the midline to the other corpus. The suture is
placed so that, as it is tied, the knot is buried between the is elevated with its encased neurovascular bundle as de-
corpora as they roll toward each other (fig. 1, E). Usually 2 or scribed in the split and roll technique to avoid any direct
3 such sutures placed in the region of maximum curvature injury to these nerves. To my knowledge it is not known
suffice. Repeat artificial erection guides suture placement whether there are perforating branches of the bundles into
and confirms penile straightening (fig. 2). Urethroplasty then the corpora along the length of the mobilized Buck’s fascia
proceeds according to surgeon preference. but none is discernible with loupe magnification. Other po-
Initially the split and roll technique was performed in tential pitfalls of the technique are that the incision through
patients who required division of the urethral plate to correct the tunica albuginea may enter the erectile tissue and ad-
chordee. This technique now has been applied to patients in versely affect its function. Although this risk may be consid-
whom the urethral plate has not been divided. In these cases ered only theoretical, to my knowledge there are no published
the corpus spongiosum proximal to the meatus and the ure- studies describing the long-term followup of patients with
thral plate distal to the meatus are elevated off of the under- severe chordee who underwent plication.
lying corpora cavernosa using sharp dissection. This dissec- An alternative to plicating or shortening the long side of
tion allows access to the ventral midline and the septum may the curved penis is to increase the length of the short or
be split. Elevation of the neurovascular bundles and rota- ventral aspect of the corpora cavernosa. The surgeon incises
tional suture placement then proceed as described. In each the tunica albuginea of the ventral corpus cavernosum in the
region of maximum curvature and places a graft into the
defect that is created as the penis straightens. Various ma-
terials have been used as the grafting material, although
dermal grafts have probably been used most frequently.3– 6, 11
Most suggest that this technique necessitates staged hypos-
padias repair,6 although Hendren and Keating noted that a
1-stage procedure may be performed in certain cases.4
The concept of corporal rotation to correct ventral chordee
associated with hypospadias has been described in the
past.12–14 Koff and Eakins noted that an incision along the
ventral corporal septum allows the corpora to rotate and
straighten during erection.12 Snow described a technique of
making an initial ventral midline incision in the corpora
cavernosa and placing sutures into the dorsal lateral corpus
cavernosum to rotate the corpora.13 Kass also placed dorsally
positioned sutures to rotate the corpora, which straightened
the phallus.14 The dorsal rotational sutures of Snow13 and
Kass14 were positioned so that the neurovascular bundles lay
under the sutures when the knots were tied. In this situation
the neurovascular bundles are subject to the risk of compres-
FIG. 2. Artificial erection. A, chordee persists after division of sion injury caused by these sutures. The split and roll tech-
urethral plate, splitting of septum and clean dissection of corpus
nique involves a ventral septal incision, which facilitates the
spongiosum off of corpus cavernosum. B, straight phallus after place-
corporal rotation provided by the dorsally positioned suture.
ment of dorsal rotational sutures.
3. 1154 CHORDEE CORRECTION BY CORPORAL ROTATION
Corporal rotation created by straightening the ventral penile 4. Hendren, W. H. and Keating, M. A.: Use of dermal graft and free
urethral graft in penile reconstruction. J. Urol., 140: 1265,
curvature allows the penis to achieve its full potential length.
1988.
In the technique described the dorsal rotational sutures lie
5. Horton, C. E., Jr., Gearhart, J. P. and Jeffs, R. D.: Dermal grafts
under the neurovascular bundles and the knots are buried
for correction of severe chordee associated with hypospadias.
between the corpora cavernosa when tied. These factors
J. Urol., 150: 452, 1993.
should obviate the risk of injury to the neurovascular bundles 6. Pope, J. C., IV, Kropp, B. P., McLaughlin, K. P., Adams, M. C.,
in the long term. Rink, R. C., Keating, M. A. and Brock, J. W., III.: Penile
orthoplasty using dermal grafts in the outpatient setting.
CONCLUSIONS Urology, 48: 124, 1996.
7. Mollard, P. and Castagnola, C.: Hypospadias: the release of
The split and roll technique allows the correction of chor-
chordee without dividing the urethral plate and onlay island
dee due to corporal disproportion without requiring incisions flap (92 cases). J. Urol., 152: 1238, 1994.
into the corporal substance. It avoids the penile shortening 8. Daskalopoulos, E. I., Baskin, L., Duckett, J. W. and Snyder,
that may be caused by dorsal plication, and during erection it H. M., III.: Congenital penile curvature (chordee without hy-
allows the shortened ventral aspect of the corpora to stretch pospadias). Urology, 42: 708, 1993.
to the length of the dorsal corpus. The technique avoids the 9. Rehman, J., Benet, A., Minsky, L. S. and Melman, A.: Results of
use of grafts and allows the surgeon to proceed with 1-stage surgical treatment for abnormal penile curvature: Peyronie’s
disease and congenital deviation by modified Nesbit plication
repair. Good intraoperative results have been achieved but
(tunical shaving and plication). J. Urol., 157: 1288, 1997.
further followup is required to confirm long-term outcomes.
10. Baskin, L. S., Erol, A., Ying, W. L. and Cunha, G. R.: Anatomical
studies of hypospadias. J. Urol., 160: 1108, 1998.
REFERENCES
11. Perlmutter, A. D., Montgomery, B. T. and Steinhardt, G. F.:
Tunica vaginalis free graft for the correction of chordee.
1. King, L. R.: Hypospadias: a one-stage repair without skin graft
J. Urol., 134: 311, 1985.
based on a new principle: chordee is sometimes produced by
12. Koff, S. A. and Eakins, M.: The treatment of penile chordee using
skin alone. J. Urol., 103: 660, 1970.
corporal rotation. J. Urol., 131: 931, 1984.
2. Nesbit, R. M.: Congenital curvature of the phallus: report of
13. Snow, B. W.: Transverse corporal plication for persistent chor-
three cases with description of corrective operation. J. Urol.,
dee. Urology, 34: 360, 1989.
93: 230, 1965.
14. Kass, E. J.: Dorsal corporal rotation: an alternative technique for
3. Devine, C. J., Jr. and Horton, C. E.: Use of dermal graft to correct
chordee. J. Urol., 113: 56, 1975. the management of severe chordee. J. Urol., 150: 635, 1993.
DISCUSSION
Dr. Antoine E. Khoury. Are you concerned about lifting the neurovascular bundle along the lateral edges? Are
there no nerve perforators that enter the corpora at that point, which may impact on sensation or erectile
function on a long-term basis?
Dr. Ross M. Decter. The technique that we use, wherein we start our dissection ventrolaterally, basically allows
us to lift up the neurovascular bundles even as they spread around the lateral aspects of the phallus. You do not
see perforating nerves when you are doing the dissection. There may well be some tiny ones but you do not see
them. You can do the dissection atraumatically and get nice access to the dorsum of the penis.
Doctor Khoury. Those lateral nerve endings coming around the sides are entering the tunica albuginea and
corpora?
Doctor Decter. They may be but you do not perceive it when you are doing it.
Dr. Sava V. Perovic. In my hands the split and roll technique in the septal region is a good method and
decreases the severity of penile chordee. Rotation of the corpora cavernosa in my hands is not successful. What
do you do when chordee is in the distal part of the corpora cavernosa near the glans?
Doctor Decter. We have limited experience but we have straightened the phallus in each situation that I
mentioned using dorsal rotational sutures. In all cases that I described the main part of the curvature was in the
shaft of the phallus. There was not as much in the way of distal curvature under the glans. Two weeks ago I had
a case in which there was some glans tilt that I was not happy with after I put in some dorsal rotational sutures.
In fact, I applied your technique. I mobilized the glans completely off of the corpora cavernosa with the blood
supply coming from the neurovascular bundle and urethral plate which exposed the end of the corpora cavernosa.
Then I put a rotational suture in the distal end of the glans, which resolved the situation.
Dr. Laurence S. Baskin. I want to comment about this concept of lifting up the neurovascular bundle. The
neurovascular bundle does something. It does not just innervate the glans. There are all these piercing nerves
that specifically go into the tunica. Dr. John Duckett showed me how to do the tunica albuginea plication
procedure, which I did for many years. When we lifted up the neurovascular bundle, I am convinced that we were
cutting these little perforating nerves. Does it make a difference? We do not know but I think that we should
probably try to minimize it. I would not advocate lifting the neurovascular bundle.
Doctor Decter. When you did that procedure, you incised Buck’s fascia right over the major part of the
neurovascular bundles. I think that this procedure has a much greater chance of not injuring the bundles because
we are elevating them and not incising through them. I advocate a technique starting with dissection ventro-
laterally to try to preserve all of Buck’s fascia with its encased neurovascular bundle.
Dr. Mark Zaontz. I agree with Doctor Baskin. The nerves span out all over the dorsum of the penis and
laterally. When we make a lateral incision, we tend to cut 1 or 2 nerves but so what? My colleagues who treat
Peyronie’s disease in adults have told me that these patients have no functional or sensory deficits. Several
adults have been referred to me for hypospadias repair with chordee release. I have probably nicked a few nerves
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myself and have not seen any deficit. I think that a few nerves cut here and there is not going to make a
difference.
Doctor Baskin. It makes a difference in San Francisco. The technique that we are using in children is taken
from observations made by Dr. Tom Lue in adults. He started his technique because of complaints of patients
who underwent a plication or Nesbit type procedure that was done laterally. These patients had decreased
sensation in the glans and skin. Doctor Lue, a penile anatomist, started to put sutures in the dorsal midline or
near the urethra. Based on fetal studies that made a lot of sense. When I showed him my fetal studies, he
indicated that he had had similar findings in adult cadaver penises. We do not know what the long-term outcome
will be of placing midline sutures but I think that it is going to be good.