ObjectiveTo assess the validity of virtual-reality simulator UroMentorTM in skill training of ureteroscopy. MethodsThirty urologists were included and divided into groups A (n =18) and B (n =12 ) based on former ureteroscopy experience ( ≥ 20 or ＜ 20).Participants were assessed on their ability to perform cystoscopy,gnidewire insertion,semirigid ureteroscope advancement and basket extraction of a distal ureteric stone on the simulator.A blinded examiner assessed the subjects' performance using global rating scale (GRS).In addition,computer-generated parameters including time to complete the task,endoscope and instrument trauma,and the number of attempts to insert a guidewire were recorded as pretest.After 2 days of simulator training,they were retested with the same task. ResultsAll participants had reduced time to completion (333 ± 32 s & 228 ± 18 s,P =0.001 ) and improved GRS (24.4 ± 2.1 & 28.1 ±1.2,P =0.010).Differences were significant between the two groups in the time to completion (before 405 ±40 s & 262 ±22 s,P =0.014; after 276 ± 12 s & 179 ±9 s,P =0.000),and GRS (before 19.6 ±2.5 & 29.2 ± 1.3,P =0.009 ; after 25.0 ± 1.1 & 31.2 ± 0.7,P =0.002).Previous ureteroscopy experience was correlated to GRS (before r=0.705,after r=0.756). ConclusionThe UroMentor virtual-reality simulator is an appropriate and useful tool in training and assessing the skills of ureteroscopy.

Objective To assess the face and construct validity of a full procedural transurethral prostate resection simulator (TURPSimTM) in the training of transurethral resection of the prostate. Methods Ten experienced and thirteen inexperienced urologists (TURP experience ≥ 30 and ≤ 3 respectively) were included for TURP training on TURPSimTM. Each participant filled out a questionnaire regarding their previous experience and opinion of the usefulness of the simulator before and after performing six full procedures at level-2 difficulty. Performance was evaluated between the two groups and pre- /post-training, including GRS and objective parameters recorded on the simulator. Results The experienced group had higher GRS scores (16.3±2.6 vs 12.9±4.0, P=0.024) and prostate resection rate [(94.6±2.8)% vs (89.8±4.4)%, P=0.006]. Less blood loss [(78 ml vs 115 ml, P=0.208) and less capsule resection rate [(27.6±5.4)% vs (29.1±6.2)%, P=0.558] were detected in the experienced group than in the inexperienced group with no significant differences. After training, GRS and coagulation precision increased (14.4±3.8 vs 20.0±3.4, P<0.001; 93% vs 100%, P=0.001) ,while capsule resection rate [(28.4±5.8)% vs (20.8±3.9)%, P<0.001), blood loss (86 ml vs 76 ml, P=0.039) and injury of sphincter (5.5±2.2 vs 3.2±1.7, P<0.001) decreased in both groups. Conclusions Proof of face and construct validity is shown for this full procedural simulator to simulate the skills necessary to perform TURP. The surgical skills of urologists may be enhanced after training on the simulator.

Objective To evaluate the safety and effectiveness of three endoscopic methods for re-moval of common bile duct stones (CBDs)accompanied with periampullary diverticula(PAD).Methods A total of 154 patients hospitalized at Taizhou Hospital and Taizhou No.1 People′s Hospital of Zhejiang prov-ince from December 2012 to July 2013 were divided randomly into three groups,i.e.,EST,EPBD and ES-BD group,and received the treatment of EST,EPBD and limited EST plus EPBD (ESBD)to extract CBDs, respectively.After 12 months of follow-up,the rate of full stone clearance,stones clearance rate in one time,the rate of mechanical lithotripsy,the rate of urgent lithotripsy,the average procedures,the average removal time and the complication incidence among three groups were compared.Results The rates of stone clearance in one time in group ESBD was higher than those of group EST and group EPBD (94.12% VS 78.43%,73.08%;P <0.05)with significant difference.The average procedures in group ESBD was lower than that of group EPBD (1.08 VS 1.31,P <0.05),which also showed significant difference.The occur-rence rates of early complication in group ESBD was lower than that of group EPBD (15.69% VS 34.61%, P <0.05).The occurrence rates of post-ERCP hyperamylasemia in group ESBD was lower than that of group EPBD (5.88% VS 21.15%)with significant difference (P <0.05).The incidence of pneumobilia in group EST was higher than those of group EPBD (52.27% VS 26.19%,P =0.013)and group ESBD (52.27%VS 27.66%,P =0.016).Conclusion The stone extraction efficiency of ESBD is better than that of EST and EPBD.Compared with conventional EST,ESBD shows similar safety level,and is safer than EPBD.So ESBD is a safe and effective method to remove CBDs with PAD.

Objective To investigate the clinical results of free super-thin peroneal artery perforator flap containing neurovascular axis in reconstruction of hand or foot soft tissue defects.Methods A retrospective case series study was made on 23 cases of hand or foot soft tissue defects admitted from January 2006 to March 2013.There were 16 males and 7 females,with a mean age of 33 years (range,17-51 years).Wounds were located in dorsal hand (n =12),dorsal pedis or amputated forefoot (n =8),greater thenar (n =2) and index finger (n =1) respectively.Defects ranged in size from 5.0 cm × 3.5 cm to 11.5 cm × 7.5 cm.Flap elevating was performed underneath the deep fascia and the perforator supplying the flap was dissected thoroughly,ligated and cut at the location arose from the peroneal artery.Most of the deep fascia except stripe shaped areas along the main blood supply chains was moved sharply and the fat underlying thinned primarily to the subdermal vascular network.After transferred to the recipient site,the flaps were revascularized by anastomosis of the perforating artery and its venae comitantes to appropriate recipient vessels.A total of 15 cases received innervated flap reconstruction.Flap vascularity and cosmetic results were recorded.Hand function was evaluated with the standard set up by the hand surgery branch of Chinese Medical Association.For foot reconstruction,shoe wearing status,gait,pressure-sore,flap sensibility,donor site appearance and complications were evaluated.Results All flaps were transplanted successfully with satisfactory cosmetic results,except that one flap used to cover dorsal ring finger defect left slightly bulky appearance.Mean duration of follow-up was 19 months (range,11-26 months).For hand reconstruction,the functional results were excellent in 6 cases and good in 9 cases.Repairing of foot defects with the flaps caused no problem of shoe wearing and no sore occurred.Normal gait was acquired except two cases of partially amputated foot.If innervated,flap sensibility was restored at least to the degree of S3.Protective sensation and touchpressure sensation were restored in eight non-innervated cases,and two of them were recovered to the degree of S3.There was only suture or small grafting scars on the donor leg and partially sensibility loss of lateral foot without functional defects in 13 cases.Conclusion Free super-thin peroneal artery perforator flap containing neurovascular axis is an easy and reliable technique that can attain satisfactory results for accurate coverage of hand or foot soft tissue defects.

Objective To explore the pathologic features and distribution characteristics of upper gastrointestinal submucosal tumors (SMT).Methods From January 2013 to December 2017,at Department of Gastroenterology of Taizhou Hospital Affiliated to Wenzhou Medical University,clinical data of 1 182 hospitalized patients with 1 237 upper gastrointestinal SMT who underwent endoscopic therapy and diagnosed by pathology and immunohistochemistry was retrospectively analyzed including the pathological types,tumor of locations,endoscopic findings,layer of origin and tumor size.Results There were 473 esophageal SMT,including 387(81.8％) leiomyomas,located in the mucosal muscularis or muscularis propria;and 59(12.5％)cysts located in the submucosa or mucosal muscularis.There were 138(29.2％) lesions,159(33.6％) lesions and 176(37.2％) lesions in the upper,middle and lower esophagus respectively,and the most common type was leiomyoma.A total of 723 tumors were gastric SMT,among them 284 (39.3％) lesions were gastrointestinal stromal tumors (GIST) and 273(37.8％) lesions were leiomyomas,and all located in the muscularis propria.A total of 69(9.5％) lesions located at cardia,the common types were leiomyoma (55 lesions,79.7％) and GIST (nine lesions,13.0％).A total of 239 (33.1％) lesions located at gastric fundus,the common types were GIST (152 lesions,63.6％) and leiomyoma (79 lesions,33.1％).A total of 280 (38.7％) lesions located at gastric body,the common types were leiomyoma (138 lesions,49.3％) and GIST (111 lesions,39.6％).A total of 127 (17.6％) lesions located at gastric antrum,the common types were heterotopic pancrease (71 lesions,55.9％) and lipoma (26 lesions,20.5％),and all were located in the submucosa,some involved the muscularis propria.There were six (0.8％) lesions at gastric angle,and two (0.3％) at gastrointestinal anastomosis.Forty-one lesions were duodenal SMT,among them 23(56.1％) located at duodenal bulb,the common types were cyst (10 lesions,43.5％),lipoma (five lesions,21.7％) and heterotopic pancrease (five lesions,21.7％).A total of 18(43.9％) lesions located at descending duodenum,the common types were lipoma (nine lesions,50.0％) and cyst (five lesions,27.8％),and all lesions located in the submucosa.Conclusions The most common type of SMT in the esophagus and cardia is leiomyoma,however the SMT in gastric fundus and body are mostly leiomyomas and GIST,while in gastric antrum,most SMT are heterotopic pancreases and lipomas.In duodenal bulb and descending duodenum,the common types of SMT are cyst and lipoma.

Objective: To report operative techniques and clinical results of free sural cutaneoadipofascial flap containing the neurovascular axis based on a dominant peroneal perforating artery (DPPA, with a caliber≥0.8 mm) and its concomitant veins for reconstruction of dorsal forefoot soft tissue defects. Methods: The flap was applied in 32 cases with middle to large soft tissue defects in the dorsal forefoot from Aug. 2009 to Dec. 2014. DPPAs arising from the posterolateral intermuscular septum was located and assessed preoperatively with color Doppler flow image and computed tomography angiography. According to the location, size, and shape of the defects, one of these DPPAs was chosen for flap planning. The flap was harvested from the posterolateral aspect of the leg. The neighboring neurovascular axis (one or more of that of the sural nerve, the medial cutaneous nerve, the lateral cutaneous nerve of calf and the sural communicating nerve) was included to ensure vascular supply. According to skin laxity of the donor site, the width of the full harvesting part which should be able to cover the region of the recipient site where pressure and friction force were prominent while wearing shores was decided; the rest was harvested as an adipofascial flap (without skin) to get enough size. After transfer to recipient site, the flap was revascularized by anastomosing the perforating artery and its venae comitantes with appropriate recipient vessels, and reinnervated (antegrade or retrograded methods). Skin grafting was performed on the adipofascial surface of the flap primarily or secondarily. The defects in donor site of the leg was closed directly. Results: All flaps (ranged from 7.5 cm×5.0 cm to 23.0 cm×13.0 cm) were transplanted successfully, and no vascular or donor site problems occurred. All primary skin grafts (19 cases) was partially lost, but only 2 of them need a second grafting. Adipose necrosis occurred in 4 of 13 cases receiving secondary grafting but only needed wound care before surgery. Following up for 11-26 months showed both satisfactory functional and cosmetic results without problems of shoe wearing. Flap sensibility restored at least to the degree of S3. Conclusions The cutaneoadipofascial flap combines the advantages of perforator, neurocutaneous axis, free and adipofascial flaps leaving only suture scar in the donor leg, and is a satisfactory method for free-style and acute coverage of dorsal forefoot defects.

Objective To report our efficacy of one-stage definite treatment of Gustilo type Ⅲ open fractures of long bone by plate osteosynthesis.Methods A retrospective case series study was conducted of the 69 cases who had undergone plate osteosynthesis for one-stage definite treatment of Gustilo type Ⅲ open fractures of long bone from January 2006 to June 2016 at Microsurgery and War Trauma Center of Chengdu Military Command,59 Hospital of Chinese PLA.They were 47 males and 22 females with an average age of 34.2 years (from 2 to 62 years).There were 27 shaft fractures of tibia or fibula (13 cases of type ⅢA,12 cases of type Ⅲ B and 2 cases of type Ⅲ C),4 fractures of distal tibia (2 cases of type Ⅲ A and 2 cases of type ⅢB),14 shaft fractures of ulna or radius (9 cases of type ⅢA,3 cases of type ⅢB and 2 cases of type Ⅲ C),12 factures of humeral shaft (7 cases of type Ⅲ A,3 cases of type Ⅲ B and 3 cases of type Ⅲ C),3 fractures of distal humerus (all type ⅢC),6 fractures of femoral shaft (5 cases of type ⅢA and one type Ⅲ C),and 3 fractures of distal femur (2 cases of type ⅢA and one type ⅢC).The intervals between injury and operation ranged from 4 to 17 hours,averaging 9.6 hours.After thorough debridement,osteosynthesis was performed with locking compression plate,limited contact dynamic compression plate or/and reconstruction locking plate,or 1/3 tubular plate.Direct closure with decreased tension or without tension was used for type Ⅲ A injury;deep open defects were repaired with perforator flaps,neurovascular axis flaps,traditional axis flaps and muscular flaps,or local flaps;limb reconstructions included neurovascular repair in 12 cases,tendon and ligament repair in 5 cases,and muscle reconstruction in 3 cases.Superficial defects were covered by skin grafts simultaneously or secondarily.Results The duration of hospitalization averaged 19 days (from 5 to 37 days).Partial necrosis occurred in one case of sural neurovascular axis flap.Superficial infection with multiple antibiotic-resistant bacteria occurred in 2 cases.Follow-up for the 69 patients ranged from 12 to 27 months (average,19.2 months).No deep bone infection occurred.Implant breaking occurred in 4 cases and implant loosening in one.The implant failures were corrected by change into intramedullary nails or plate refixation (respectively in 2 cases) in addition to bone graft.Bone union was achieved after 5 to 15 months (average,7.7 month)with satisfactory aesthetic and functional outcomes.Conclusion For patients with Gustilo type Ⅲ open fracture of long bone,especially those with metaphyseal,intraarticular or upper limb fracture and pediatric ones,plate osteosynthesis can be a satisfactory one-stage definite treatment besides intramedullar nailing and external fixation,providing that through debridement and satisfactory soft-tissue coverage can be achieved.