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.
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.
A profile of Chatham County, its past and current growth, the population growth experienced by neighboring municipalities, and economic development projects in the pipeline. December 3, 2015
Presentation from Chatham Economic Development Corporation's annual Opportunity Chatham breakfast meeting. Includes Census tract data about incoming, housing, poverty, and more.
A profile of Chatham County, its past and current growth, the population growth experienced by neighboring municipalities, and economic development projects in the pipeline. December 3, 2015
Presentation from Chatham Economic Development Corporation's annual Opportunity Chatham breakfast meeting. Includes Census tract data about incoming, housing, poverty, and more.
Head and neck cancer reconstruction is arguably the
most challenging area of reconstruction for the reconstructive
surgeon. A clear understanding of the principles of use of local flaps and a comprehensive understanding of the anatomy of these flaps provides the head and neck surgeon with a plethora of local and regional options for primary and secondary reconstruction.
Flaps for reconstruction/periodontics courses by indian dental academyIndian dental academy
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
Indian Dental Academy: will be one of the most relevant and exciting training center with best faculty and flexible training programs for dental professionals who wish to advance in their dental practice,Offers certified courses in Dental implants,Orthodontics,Endodontics,Cosmetic Dentistry, Prosthetic Dentistry, Periodontics and General Dentistry.
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.
Acute scrotum is a general term referring to an emergency condition affecting the contents or the wall of the scrotum.
There are a number of conditions that present acutely, predominantly with pain and/or swelling
A careful and detailed history and examination, and in some cases, investigations allow differentiation between these diagnoses. A prompt diagnosis is essential as the patient may require urgent surgical intervention
Testicular torsion refers to twisting of the spermatic cord, causing ischaemia of the testicle.
Testicular torsion results from inadequate fixation of the testis to the tunica vaginalis producing ischemia from reduced arterial inflow and venous outflow obstruction.
The prevalence of testicular torsion in adult patients hospitalized with acute scrotal pain is approximately 25 to 50 percent
Report Back from SGO 2024: What’s the Latest in Cervical Cancer?bkling
Are you curious about what’s new in cervical cancer research or unsure what the findings mean? Join Dr. Emily Ko, a gynecologic oncologist at Penn Medicine, to learn about the latest updates from the Society of Gynecologic Oncology (SGO) 2024 Annual Meeting on Women’s Cancer. Dr. Ko will discuss what the research presented at the conference means for you and answer your questions about the new developments.
micro teaching on communication m.sc nursing.pdfAnurag Sharma
Microteaching is a unique model of practice teaching. It is a viable instrument for the. desired change in the teaching behavior or the behavior potential which, in specified types of real. classroom situations, tends to facilitate the achievement of specified types of objectives.
Couples presenting to the infertility clinic- Do they really have infertility...Sujoy Dasgupta
Dr Sujoy Dasgupta presented the study on "Couples presenting to the infertility clinic- Do they really have infertility? – The unexplored stories of non-consummation" in the 13th Congress of the Asia Pacific Initiative on Reproduction (ASPIRE 2024) at Manila on 24 May, 2024.
HOT NEW PRODUCT! BIG SALES FAST SHIPPING NOW FROM CHINA!! EU KU DB BK substit...GL Anaacs
Contact us if you are interested:
Email / Skype : kefaya1771@gmail.com
Threema: PXHY5PDH
New BATCH Ku !!! MUCH IN DEMAND FAST SALE EVERY BATCH HAPPY GOOD EFFECT BIG BATCH !
Contact me on Threema or skype to start big business!!
Hot-sale products:
NEW HOT EUTYLONE WHITE CRYSTAL!!
5cl-adba precursor (semi finished )
5cl-adba raw materials
ADBB precursor (semi finished )
ADBB raw materials
APVP powder
5fadb/4f-adb
Jwh018 / Jwh210
Eutylone crystal
Protonitazene (hydrochloride) CAS: 119276-01-6
Flubrotizolam CAS: 57801-95-3
Metonitazene CAS: 14680-51-4
Payment terms: Western Union,MoneyGram,Bitcoin or USDT.
Deliver Time: Usually 7-15days
Shipping method: FedEx, TNT, DHL,UPS etc.Our deliveries are 100% safe, fast, reliable and discreet.
Samples will be sent for your evaluation!If you are interested in, please contact me, let's talk details.
We specializes in exporting high quality Research chemical, medical intermediate, Pharmaceutical chemicals and so on. Products are exported to USA, Canada, France, Korea, Japan,Russia, Southeast Asia and other countries.
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
These lecture slides, by Dr Sidra Arshad, offer a quick overview of physiological basis of a normal electrocardiogram.
Learning objectives:
1. Define an electrocardiogram (ECG) and electrocardiography
2. Describe how dipoles generated by the heart produce the waveforms of the ECG
3. Describe the components of a normal electrocardiogram of a typical bipolar leads (limb II)
4. Differentiate between intervals and segments
5. Enlist some common indications for obtaining an ECG
Study Resources:
1. Chapter 11, Guyton and Hall Textbook of Medical Physiology, 14th edition
2. Chapter 9, Human Physiology - From Cells to Systems, Lauralee Sherwood, 9th edition
3. Chapter 29, Ganong’s Review of Medical Physiology, 26th edition
4. Electrocardiogram, StatPearls - https://www.ncbi.nlm.nih.gov/books/NBK549803/
5. ECG in Medical Practice by ABM Abdullah, 4th edition
6. ECG Basics, http://www.nataliescasebook.com/tag/e-c-g-basics
Pulmonary Thromboembolism - etilogy, types, medical- Surgical and nursing man...VarunMahajani
Disruption of blood supply to lung alveoli due to blockage of one or more pulmonary blood vessels is called as Pulmonary thromboembolism. In this presentation we will discuss its causes, types and its management in depth.
New Directions in Targeted Therapeutic Approaches for Older Adults With Mantl...i3 Health
i3 Health is pleased to make the speaker slides from this activity available for use as a non-accredited self-study or teaching resource.
This slide deck presented by Dr. Kami Maddocks, Professor-Clinical in the Division of Hematology and
Associate Division Director for Ambulatory Operations
The Ohio State University Comprehensive Cancer Center, will provide insight into new directions in targeted therapeutic approaches for older adults with mantle cell lymphoma.
STATEMENT OF NEED
Mantle cell lymphoma (MCL) is a rare, aggressive B-cell non-Hodgkin lymphoma (NHL) accounting for 5% to 7% of all lymphomas. Its prognosis ranges from indolent disease that does not require treatment for years to very aggressive disease, which is associated with poor survival (Silkenstedt et al, 2021). Typically, MCL is diagnosed at advanced stage and in older patients who cannot tolerate intensive therapy (NCCN, 2022). Although recent advances have slightly increased remission rates, recurrence and relapse remain very common, leading to a median overall survival between 3 and 6 years (LLS, 2021). Though there are several effective options, progress is still needed towards establishing an accepted frontline approach for MCL (Castellino et al, 2022). Treatment selection and management of MCL are complicated by the heterogeneity of prognosis, advanced age and comorbidities of patients, and lack of an established standard approach for treatment, making it vital that clinicians be familiar with the latest research and advances in this area. In this activity chaired by Michael Wang, MD, Professor in the Department of Lymphoma & Myeloma at MD Anderson Cancer Center, expert faculty will discuss prognostic factors informing treatment, the promising results of recent trials in new therapeutic approaches, and the implications of treatment resistance in therapeutic selection for MCL.
Target Audience
Hematology/oncology fellows, attending faculty, and other health care professionals involved in the treatment of patients with mantle cell lymphoma (MCL).
Learning Objectives
1.) Identify clinical and biological prognostic factors that can guide treatment decision making for older adults with MCL
2.) Evaluate emerging data on targeted therapeutic approaches for treatment-naive and relapsed/refractory MCL and their applicability to older adults
3.) Assess mechanisms of resistance to targeted therapies for MCL and their implications for treatment selection
2. ONE-STAGE REPAIR OF HYPOSPADIAS 1233
lar and frenal portions of the distal urethra. The rest of the
slightly protruding urethral edge is everted and sutured to
the glanular edge in a semi-cufffashion. When complete, the
vertically slit meatus opens at the most distal end of the
Step l. Outlining of skin incision snd dartos mobilization glans, which was restored to a normal cone shape from a
somewhat ventrally tilted and globular shape (figs. 2,1 and 3
to 5).
Step 2. In step 6 Byars' flaps are created with the dorsal foreskin
and its subcutaneous tissue (figs. 2, J and 3 to 5). In step 7
___ ehordee _ the skin is closed (figs. 2, K and 3 to 5). Steps 6 and 7 are
(-) (+) essentially the same as reported previously.lO, 11However, in
proximal hypospadias when a pro-penile bifid scrotum is
quot;quot; Harvesting PF / often a concurrent deformity, at step 1 the scrotum must be
/ Bilateral mobilized extensively and at step 6 Byars' flaps must be created
Unilateral PF PF with with enough subcutaneous tissue to reposition it ventral and
posterior to the penile shaft.11 The specific details of each
step have been described previously.1O-12
Postoperatively, all cases are managed with urethral
drainage using an indwelling 6F silicone catheter for 1week
Step 3. in those with meatal based manta-wing flap and for 2 weeks in
those with parameatal based and fully extended circumfer-
ential foreskin flap. Wound dressing and treatment after
Step 4. removing the catheter have been reported previously.lO. 11
Step S.
RESULTS
In the last 10 years 120 patients 2 to 12 years old (mean
Step 6. Byarsization of dorsal foreskin sud subcutaneous tissue age 3.7 years) underwent this procedure, including 50
treated with meatal based manta-wing flap and 70 treated
with parameatal based and fully extended circumferential
Step 7. foreskin flap. In a third of the procedures with parameatal
based and fully extended circumferential foreskin flap dartos
FIG. 1. Flowehart of operative teehnique. PF, parameatal flap. mobilization alone was insufficient to release the chordee in
OUPF-II, l-stage urethroplasty with meatal based manta-wing fore- what seemed to be distal hypospadias. Overall 70 cases were
skin flap. OUPF-N, l-stage urethroplasty with parameatal based cured primarily without complications. Small fistulas oc-
and fully extended eireumferential foreskin flap. curred in 8 cases but they all healed within 2 months. In-
cluding these cases, primary success was accomplished in
82% (41 of 50 cases) and in 53% (37 of 70 cases). Complica-
correction of chordee (step 2) there should not be any tension tions necessitated secondary repair in 42 cases, including
in anchoring the neourethra to the glans (figs. 4, K to M mea tal stricture requiring recession or glanular dehiscence
and 5). with meatal recession in 15 (3 with meatal based manta-wing
In step 5 the glans wings are approximated over the neo- flap, and 12 with parameatal based and fully extended cir-
urethra as well as paraglanular foreskin to cover the glanu- cumferential foreskin flap), urethrocutaneous fistula in 21 (6
D!§
FIG. 2. Sehematie of l-stage urethroplasty with meatal based manta-wing foreskin flap
3. 1234 ONE-STAGE REPAIR OF HYPOSPADIAS
FIG. 3. Photographof l-stage urethroplastywith meatal based manta-wingforeskinflap
with meatal based manta-wing flap, and 15 with parameatal success rate was 91% (96% with meatal based manta-wing
based and fully extended circumferential foreskin flap) and flap, and 87% with parameatal based and fully extended
urethral stricture in 6 with parameatal based and fully ex- circumferential foreskin flap). Functional and cosmetic out-
tended circumferential foreskin flap. Secondary procedures come was satisfactory with both techniques (fig. 6). Addi-
in 32 cases (extension urethroplasty in 15 and fistula closure in tional repair is planned in 13 cases (10 secondary, 2 tertiary
17) provided satisfactory results in 29. Thus, the overall and 1 quaternary).
4. ONE-STAGE REPAIR OF HYPOSPADIAS 1235
H
~
i n
FIG. 4. Sehematie of l-stage urethroplasty with parameatal based and fully extended eireumferential foreskin flap
e A B o
Step 7
FIG. 5. Photograph of l-stage urethroplasty with parameatal based and fully extended eireumferential foreskin flap
5. 1236 ONE-STAGE REPAIR OF HYPOSPADIAS
A advancement and glanuloplasty or the flip-flap technique is
probably indicated.
With our procedure the neourethra is in natural continuity
with the old urethra, allowing less chance of complication at
the junction. Urethras thus formed continue to grow, as
illustrated by our 13-year-old patients. Compared to the
glans piercing technique, our meatal glanuloplasty seems to
be embryologically as well as anatomically more sound,9 and
it provides cosmetically and functionally satisfactory results.
Moreover, the skin closure allows a pro-penile scrotum to be
repositioned ventral and posterior to the penile shaft, which
enables substantial correction of concurrent deformities even
in the severest form ofhypospadias, all in a single stage. We
recommend that the l-stage urethroplasty with parameatal
foreskin flap be added to the armamentarium as a simple and
reliable l-stage method for all types of hypospadias with a
reasonable rate of success.
FIG. 6. Outcome of l-stage urethroplasty with meatal based
manta-wing foreskin flap (A), and parameatal based and fully ex-
tended circumferential foreskin flap (E). REFERENCES
1. Duckett, J. W.: Hypospadias. In: Campbell's Urology, 6th ed.
Edited by P. C. Walsh, A. B. Retik, T. A. Stamey and E. D.
Vaughan, Jr. Philadelphia: W. B. Saunders Co., vol. 2, chapt.
DISCUSSION 50, p. 1897, 1992.
2. Wacksman, J., Sheldon, C. and King, L. R: Distal hypospadias
Although it is an established fact that chordee is some- repair. In: Reconstructive Urology. Edited by G. Webster, R.
times absent or is relieved by dartos mobilization alone, it is Kirby, L. King and B. Goldwasser. Boston: Blackwell Scien-
difficult to predict the severity of chordee preoperatively. In tific, vol. 2, chapt. 53, pp. 749-762, 1993.
glanular or coronal hypospadias it is absent in most cases, 3. Ehrlich, R. M. and Scardino, P. T.: Surgical correction ofscrotal
thus enabling repair with meatal advancement and glanulo- transposition and perineal hypospadias. J. PedoSurg., 17: 175,
1982.
plasty, and/or the flip-flap technique.2 In other distal-to- 4. Woodard, J. R and Parrott, T. S.: Management of severe peri-
penoscrotal hypospadias dartos mobilization alone is often neal hypospadias with bifid scrotum. J. Urol., part 2, 145:
adequate to relieve chordee,7 allowing various l-stage re- 245A, abstract 132, 1991.
pairs with preservation of the urethral plate.13. 14Artificial 5. Duckett, J. W.: Hypospadias. In: Reconstructive Urology. Edited
erection with the patient under anesthesia before skin inci- by G. Webster, R Kirby, L. King and B. Goldwasser. Boston:
sion may be helpful in selecting the operation of choice but it Blackwell Scientific, vol. 2, chapt. 54, pp. 763-780, 1993.
seems cumbersome. Furthermore, in what appears to be dis- 6. Koyanagi, T., Nonomura, K and Asano, Y.: One stage urethro-
tal-to-penoscrotal hypospadias dartos mobilization alone plasty with parameatal foreskin-flap (OUPF): simple method
fails to relieve chordee in a third of the cases.6 Although universally applicable to all types of hypospadias repair. J.
Urol., part 2,147: 317A, abstract 419,1992.
urethral mobilization may help, 15-17if it does not the ure- 7. Marshall, M., Jr., Beh, W. P., Johnson, S. H., III, Price, S. E., Jr.
thra must be transected before undergoing l-stage repair, of and Barnhouse, D. H.: Etiologic consideration in penoscrotal
which the currently most reliable is the transverse preputial hypospadias repair. J. Urol., 120: 229, 1978.
island flap (the Duckett procedure).18 This technique has 8. Turner-Warwick, R: Hypospadiac and epispadiac retrievo-
been used in the severest form ofhypospadias, combining the plasty. In: Reconstructive Urology. Edited by G. Webster, R
Thiersch-Duplay urethroplasty of the proximal urethra.3 A Kirby, L. King and B. Goldwasser. Boston: Blackwell Scien-
simple method applicable to all types of hypospadias is de- tific, vol. 2, chapt. 55, pp. 781-794, 1993.
sired because of such unexpected situations. 9. Altemus, A. R and Hutchins, G. M.: Development ofthe human
The l-stage urethroplasty with parameatal foreskin flap anterior urethra. J. Urol., 146: 1085, 1991.
10. Koyanagi, T., Nonomura, K, Asano, Y., Gotoh, T. and Togashi,
technique as described is unique in this regard. It requires no M.: Onlay urethroplasty with parameatal foreskin flap for
planned skin incision, as in most repairs, except the initial distal hypospadias. Eur. Urol., 19: 221, 1991. _
incision (step 1), which is essentially the same regardless of 11. Koyanagi, T., Nonomura, K, Kakizaki, H., Takeuchi, 1. and
the type ofhypospadias. The technique differs only at step 4. Yamashita, T.: Experience with one-stage repair of severe
After dartos mobilization there are just 2 ways to form the proximal hypospadias: operative technique and results. Eur.
neourethra (with meatal based manta-wing flap, and with Urol., 24: 106, 1993.
parameatal based and fully extended circumferential fore- 12. Nonomura, K, Koyanagi, T., Kakizaki, H., Takeuchi, 1. and
skin flap), the choice ofwhich is made at the time of artificial Moriya, K: One-stage repair with parameatal foreskin flap for
erection. Allowing this intraoperative choice depending on all types ofhypospadias. J. Urol., part 2,147: 188A,videotape
V-1,1992.
the degree of remaining chordee considerably simplifies the 13. King, L. R: Hypospadias-a one-stage repair without skin graft
procedure. based on a new principIe: chordee is sometimes produced by
Viability of the parameatal foreskin flap even in cases the skin alone. J. Urol., 103: 660, 1970.
treated with parameatal based and fully extended circumfer- 14. Elder, J. S., Duckett, J. W. and Snyder, H. M.: Onlay island flap
ential foreskin flap is well established.19 When blood flow in the repair ofmid and distal hypospadias without chordee. J.
measured on laser Doppler was compared at the tip of the Urol., 138: 376, 1987.
parameatal flap before and after harvesting there was only 15. Koyanagi, T., Matsuno, T., Nonomura, K and Sakakibara, N.:
an 18% reduction with parameatal based and fully extended Complete repair of severe penoscrotal hypospadias in 1 stage:
circumferential foreskin flap. In comparison to the meatal experience with urethral mobilization, wing flap-flipping ure-
throplasty and quot;glanulomeatoplasty.quot; J. Urol., 130: 1150,
based ventral midline flap, the parameatal flap also has 1983.
considerably better microcirculatory parameters (for exam- 16. Mollard, P., Mouriquand, P. and Felfela, T.: Application of the
ple flow reduction rates with the flip-flap and with meatal onlay island flap urethroplasty to penile hypospadias with
based manta-wing flap were 73% and 33%, respectively)/9 severe chordee. Brit. J. Urol., 68: 317,1991.
which is why we prefer the latter procedure when meatal 17. Monfort, G., Bretheau, D., di Benedetto, V. and Bankole, R:
6. ONE-STAGE REPAIR OF HYPOSPADIAS 1237
Posterior hypospadias repair: a new technical approach. Mo- The authors ask a question in the title: quot;Is there no simple method
bilization ofthe urethral plate and Duplay urethroplasty. Eur. universally applicable to all types of hypospadias?quot; Clearly, the
Urol., 22: 137, 1992. answer is, quot;No.quot;
18. Duckett, J. W.: The island flap technique for hypospadias repair. A. B. Belman
Urol. Clin. N. Amer., 8: 503, 1981.
19. Nonomura, K, Koyanagi, T., Imanaka, K and Asano, Y: Meas- Department of Urology
Children's Hospital National Medical Center
urement of blood flow in the parameatal foreskin flap for Washington, D. C.
urethroplasty in hypospadias repair. Eur. Urol., 21: 155, 1992.
Reply by Authors. In our earlier series in which only 1 of us (T. K)
EDITORIAL COMMENT performed the operation the complication rate associated with a
secondary operation was 8% (2 of25 cases) with meatal based manta-
The authors present their extensive ongoing experience with what wing foreskin flap (reference 10 in article) and 33% (6 of 18 cases)
I perceive as a complex hypospadias repair. They are to be compli- with parameatal based and fully extended circumferential foreskin
mented on their perseverance and on the illustrations, which finally flap. During the ensuing years a number of junior surgeons per-
clarifY their technique for me. However, even with their vast expe- formed the repair, which may explain the relatively higher compli-
rience the complication rate is higher with their procedure than that cation rate in the present series. Others have reported an even
currently achieved with other l-stage techniques. For hypospadias higher incidence (50%) of secondary operations with pedicle tube
without chordee they report an 18% complication rate (with meatal urethroplasty and other techniques (reference 4 in article).2 Under
based manta-wing flap). This group is amenable to a meatal based our current national health program under which every citizen is
flap (Mathieu) or the currently popular onlay repair. Complications entitled to uniform access to health care provided by the government
necessitating reoperation should be less than 5% and reoperations
are being performed by most on an outpatient basis, some without or an insurance company there is no urgency or impetus in promot-
the use of stents (the authors report 1 week of urethral stenting in ing short hospital stay or outpatient surgery. Rather the providers
this group). prefer inpatient care until the wound heals, which may explain the
The authors also report a 47% complication rate (1 applaud their longer urethral catheter drainage and which we plan to shorten in
honesty) with parameatal based and fully extended circumferen- the future. There might have been a few cases in which the pedicle
tial foreskin flap repair. They state that vascularity of the flap was harvested poorly, compromising its vasculature and con-
para meatal foreskin has been proved to be excellent on laser tributing to complications. That the flap was harvested adequately
Doppler. In my experience mea tal stenosis (and stricture?) is a was confirmed by the laser Doppler data. Consequently, the cause of
consequence of diminished vascularity. Judging from their results complication must lie elsewhere. Inadequate coverage of the neoure-
I suspect that vascularity is not as excellent as they believe. thra with Byars' foreskin flaps can result in fistula, as can inade-
Reoperation rate, even for those with severe hypospadias, should quate splitting and tight reapproximation of the glans over the
not exceed 15%. In our experience using a de-epithelialized flap or neourethra with glanular deshiscence and meatal recession. The
tunica vaginalis to cover the transverse island tube fewer than answer to the question in the title is quot;No,quot; when one considers the
10% of cases require a secondary procedure. I agree with their complexity of the deformity and enormous task demanded for its
comment that the currently most reliable repair is the transverse repair but quot;Yes,quot;when it comes to the choice ofthe repair applicable
preputial island flap. to all types of hypospadias.
The argument that they advance (that the initial skin incision is
similar for all degrees of hypospadias) to justify their assertion that 1. Nonomura, K, Koyanagi, T., Imanaka, K, Togashi, M., Asano,
the repair is applicable generally confuses me. Other than with Y and Tanda, K: One-stage total repair of severe hypospadias
meatal based repairs the skin incision for all others is basically the with scrotal transposition: experience in 18 cases. J. Pedo
same, subcoronal and proximal to the hypospadiac meatus. If an Surg., 23: 177, 1988.
onlay is used the urethral plate is spared. The erection test can then 2. Dewan, P. A., Dineen, M. D., Winkle, D., DuflY, P. G. and
be performed after the skin is dissected toward the penile base, if the Ransley, P. G.: Hypospadias: Duckett pedicle tube urethro-
surgeon prefers. plasty. Eur. Urol., 20: 39, 1991.