Unilateral Renal Tumor Cryoablation and Contralateral Radical Nephrectomy of Bilateral Renal Tumors by Transumbilical 3D Multichannel Laparoendoscopic Single-Site Surgery.

Background: Unilateral renal tumor cryoablation and contralateral radical nephrectomy of bilateral renal tumors were performed by transumbilical three-dimensional (3D) multichannel laparoendoscopic single-site (LESS) surgery, in an attempt to verify the feasibility and safety of the procedure, sum up the operational experience, and evaluate the surgical outcome. Case Presentation: This was a 47-year-old female patient with a body mass index of 27.34 kg/m2 without backache, low back pain, hematuria, urinary urgency, frequent urination, dysuria, and other symptoms. Contrast-enhanced CT scan of the kidney on admission showed four masses in the left kidney and two masses in the right kidney. Preoperative serum creatinine (SCr) was 87 µmol/L. Operation was performed under general anesthesia by first laying the patient in a left lateral position. A 2-cm longitudinal transumbilical skin incision was made to expose the right kidney for complete dissection of the two tumors. First, puncture biopsy was performed, and then two freeze-thaw cryoablation cycles for the two tumors were performed. At last, the patient was laid in a right lateral position for radical nephrectomy of the left kidney. The operative duration, cryoablation time, and estimated blood loss were 200 minutes, 40 minutes, and 100 mL, respectively. Postoperative pathological examination revealed clear-cell renal cell carcinoma. The right glomerular filtration rate tested was 42.36 mL/minute and SCr was 131 µmol/L at day 5 after surgery. There was no evidence of contrast enhancement at the cryoablative region as shown by renal contrasted CT scan performed 4 days after surgery and renal contrasted MRI scan performed 6 weeks after surgery, indicating that there was no tumor remnant or recurrence. Conclusion: Our preliminary experience shows that the treatment of bilateral renal tumors with unilateral renal tumor cryoablation and contralateral radical nephrectomy by transumbilical 3D LESS is safe, feasible, and effective. It may prove to be a viable option for patients with significant comorbidities and an insensitive treatment intention.

[Small-dose vardenafil restores erectile function after penile surgery].

OBJECTIVE: To investigate the impact of penile surgery on the erectile function of the patient and to evaluate the role of small-dose vardenafil in restoring the impaired penile erection. METHODS: Sixty cases of penile cavernosum surgery were equally and randomly divided into a vardenafil and a control group, the former treated 5 - 7 days after surgery with 10 mg vardenafil every other day, while the latter given vitamin E at 100 mg once a day, both for 12 weeks. The penile erectile function of the patients was evaluated with the IIEF-5 questionnaire before surgery and at 3 and 6 months after vardenafil medication. RESULTS: The mean IIEF-5 scores of the vardenafil group were 18.83 +/- 2.98 and 20.13 +/- 2.98 at 3 and 6 months after vardenafil medication, significantly higher than 14.21 +/- 3.62 before surgery (P > 0.05), while that of the control group was significantly decreased at 3 months as compared with the preoperative score (13.38 +/- 2.82 versus 15.80 +/- 3.02, P < 0.05). The vardenafil group showed the highest IIEF-5 score after surgery (P < 0.05). CONCLUSION: Long-term administration of small-dose vardenafil after penile surgery helps to restore and maintain penile erectile function.

[Repair and functional reconstruction of the penis (a report of 62 cases)].

OBJECTIVE: To investigate the effects of surgery treatment on serious penile lesions and malformation. METHODS: Sixty-two patients, aged from 19 to 63 years old (mean 35 ys), were included in the study. Among them, 4 patients suffered from penis partial defection were respectively treated with restoring defective penis, penis lengthening and urethroplasty; three patients with penis completely missing were treated with penis reconstruction surgery; 22 cases with serious penile curvature were treated with the 16-dot plication technique (Lue's procedure); 15 cases with penile fracture were treated with conservative treatment for 1 case and with patch penis, corpus spongiosum, and deep penile dorsal vein ligation for 14 cases; 5 cases with post-operative complications of 3-pieces of penile prosthesis, including the prosthesis perforating to the urethra, water pump failure, broken connection tube, erection angle < 60 degrees and failure to expansion the corpus cavernosum, were treated by taking out prostheses, urethral repair cracks, replacement of the prostheses, excision of fibrosis scar and re-implantation prostheses respectively. Four cases with penis complete amputation were treated with the penis replantation; three cases of avulsion injury were treated with the replantation and free flap skin; 6 with Paget's disease of penises were treated with the lesion free skin buried in the scrotum and penis. RESULTS: All these patients were followed up for 3 months to 4 years, with the average of 9 months. Among the 4 cases of penis partial defection, 2 patients were satisfied with the penile appearance and sexual function; 1 got some satisfactory and 1 was unsatisfied. Three cases with the loss of the penis completely were satisfied with both the postoperative appearance and urination, and 1 was not satisfied. Twenty-two cases of penile curvature deformities were corrected, and one case was recurrence. Fourteen of the 15 patients with penile fracture were followed, and all got the restoration of sexual function. Among them, 5 cases with post-operative complications, including mild bending, algopareunia, subcutaneous induration, poor hardness and poor sexual pleasure, were not further treated, and another case lost; Five cases with post-operative complications of three-pieces penile prosthesis were treated successfully, and 4 of their spouses were satisfied with their sexual function after operation, only 1 of their spouse not satisfied. Among four cases with complete amputation of penis, two cases of penis were replanted successfully while two necrosis. Three cases with avulsion were treated with skin grafting successfully. All 6 cases with penile Paget's disease were followed for 2 -4 years, and free skin grafts were all survival. One patient died of brain metastases 18 months after operation and five cases were disease-free survival. CONCLUSION: The patients should be treated based on the procedure of andrological and urological surgery, together with microsurgical, flap or skin graft technique. The urologist should design personalized surgical procedure. Most of the patient's penis shape and erectile dysfunction can be reconstructed by our procedures, but some patients can not achieve the desired appearance or function of penis. New approaches of the treatment ought to be developed to restore both of the shape and function for those severe injury of the penis.

[Duckett's procedure of one-stage urethroplasty for hypospadias].

OBJECTIVE: To study the clinical effect of Duckett's procedure of one-stage urethroplasty with the transverse preputial island flap in the treatment of hypospadias. METHODS: We retrospectively studied 20 cases of hypospadias treated by Duckett's procedure of one-stage urethroplasty with the transverse preputial island flap (Group A) from 2003 to 2007. The patients ranged in age from 2 to 22 years (mean 11.3 years). Another 30 hypospadias patients aged 7 to 34 (mean 16.1) years underwent urethroplasty with mucous membrane of the bladder (Group B) in the same period. Of the 50 cases, 13 were the penile type, 33 the penoscrotal type, 2 the scrotal type, and 2 the perineal type. Catheters were indwelled in Group A, but both cystostomy and catheter indwelling were used in Group B. RESULTS: For Duckett's procedure, surgery succeeded in 17 cases (85%), urethra stenosis developed in 1 (5%) and urinary fistula in 2 (10%), which were successfully repaired 6 months after the operation. The mean operation frequency was 1.1 per patient. In Group B, the operation was accomplished in 2 stages and succeeded in 26 cases (86.7%), with postoperative development of urinary fistula in 3 (10%) and urethra stenosis in 1 (3.3%). The mean operation frequency was 2.1 per patient. The 2 cases of postoperative urethra stenosis were both cured by urethral sounding. CONCLUSION: Duckett's procedure of one-stage urethroplasty with the transverse preputial island flap is effective in hypospadias repair, with a success rate close to that of other types of operations and a low rate of postoperative complications. Compared with the use of mucous membrane of the bladder, it has the advantages of one-move accomplishment and gives a better penile appearance.

[Successive "Z" incision and skin flaps: a better procedure for penile lengthening].

OBJECTIVE: To recommend the successive "Z" incision and skin flaps as a method for repairing the wound in penile lengthening procedures. METHODS: We performed penile lengthening surgery by successive "Z" incision for 5 patients complaining of short penis, who ranged in age from 16 to 34 years (22.4 +/- 7.2), and 3 of whom had a history of urethroplasty, circumcision and penile reconstruction, respectively. The superficial suspensory ligament and part of the deep suspensory ligament of the penis were exposed and severed to release the penis, and the "Z" skin flaps sutured in a tensionless state. Drainage was necessitated by exudation and the catheter removed in 24-48 hours. The penis was wrapped up by an elastic bandage, and the stitches taken out 8-10 days after the operation. RESULTS: We achieved a mean erectile length of 8.4 cm (range 7.8-9.2 cm) after the operation, as compared with 4. 8 cm (range 4.0-5.8 cm) before the surgery. Two students of the patients obviously became active and confident. No penile contraction was noted during the 12-48 months follow-up, and both the patients and their family members were satisfied with the outcomes. CONCLUSION: Compared with the V-, M- and Z-incision, the successive "Z" incision and skin flaps can yield longer penile length, solve the problem of insufficient skin flap to cover the wound and reduce such complications as skin necrosis and infection. It is well worth recommending for patients complaining of short penis because of penile abnormality, post-operation scar on the penis or circumcision.

Penile and scrotal Paget's disease: 130 Chinese patients with long-term follow-up.

OBJECTIVES: To report a retrospective series of 130 Chinese patients with penoscrotal extramammary Paget's diseases (EMPD), with a long-term follow-up, and thus improve the diagnosis and therapy of this disease. PATIENTS AND METHODS: The history, clinical presentation, pathology, treatment, and prognosis of 130 patients were analysed. All cases were confirmed by skin biopsy, and then the patients had local wide resection to remove the involved skin and subcutaneous tissue. The large defective wound was reconstructed using a split-thickness skin graft or local flap. RESULTS: Forty-five patients were evaluated by frozen-section biopsy of the margins during surgery, five of whom had positive margins and then had an extended resection immediately. Most of these patients had local skin or adjacent scrotal flaps to cover their skin defects. Of the 130 patients, 81 had a mean (range) follow-up of 3.2 (0.5-10) years after surgery. Five of nine patients with positive margins and three (4%) of 72 with negative margins had tumour recurrence. Five patients died from metastatic disease. CONCLUSIONS: Penoscrotal EMPD needs be differentiated from other chronic dermatitis. A 3 cm surgical margin should be sufficient and frozen-section pathological examinations are necessary for some complicated conditions. Skin grafts or local flaps are good for large skin defects.