Objective To evaluate the clinical significance of retroperitoneal laparoscopic adrenalectomy for benign adrenal tumors.Methods A total of 81 cases of retroperitoneal laparoscopic adrenalectomy from March 2002 to October 2005 was retrospectively analyzed,including 21 cases of Cushing's syndrome,57 cases of aldosterone-preducing adenoma,2 cases of adrenal pheochromocytoma,and 1 case of bilateral adrenocortical hyperplasia.Three trocars were introduced at the lumbar part and a retroperitoneal space was established by blunt dissection with the camera assembly.The tumor was removed by using a harmonic scalpel.Results The procedure was successfully completed in all the 81 cases,with an operation time of 20~140 min(mean,60 min) and an intraoperative blood loss of 20~100 ml(mean,45 ml).There was no need of blood transfusion intra-and post-operatively.Retroperitoneal hematoma occurred in 1 case post-operatively.Follow-up examinations in 37 cases for 3~18 months(mean,11 months) showed normal blood pressure,stature and laboratory findings.Conclusions Retroperitoneal laparoscopic adrenalectomy has advantages of minimal invasion,little blood loss,quick post-operative recovery,and low complication incidence.It should be considered as the first choice for treating benign adrenal tumors.

Objective To investigate the application of OSCE evaluation system on the medical skills examination of clinical medical students and the significance of this system on the training of their medical skills.Methods 20 teachers examed 150 students by the OSCE evaluation system with 4 test stations,by comparing the score of the students of different test stations by one-way ANOVA and evaluating the system by questionnaire survey with Likert 5 on the degree of satisfaction and Likert 3 on effects and intrinsic influencing factors of the system.Results The score of the first and forth test stations was lower than that in the other stations(P＜0.05).8/5.48％ students and 1/5％ teachers were not satisfied with the system.The OSCE evaluation system could exam the psychological diathesis,ability of communication,cooperation,and clinical thinking,practical skill of the students and its effects are moderate (the score was more than 2.0).Evaluation on the intrinsic influencing factors:Students considered the questions were more difficulty in the 2nd,3rd,1st,4th test stations order.4/20％ teachers considered the questions of the second test station was easy.8/40％ teachers considered the duration of the second test station was too long.More than 70％ students and teachers considered the other indexes were rational.Conclusion The OSCE evaluation system can play an effective role in directing the teaching and learning.It can also help to culture the comprehensive capacity of the students.We should gradually improve the design of the system by considering the intrinsic influencing factors.

BACKGROUND: A long-term follow-up indicates that orthotopic ileal neobladder can cause acid-base balance and nutritional metabolic disorder. Otherwise, a long mesenterium is necessary to balance the tension of bladder at pelvic cavity and urinary inosculation due to a high position of ileum. On the contrary, sigmoid neobladder is near by urinary canal, and orthotopic sigmoid neobladder as a bladder substitute after radical cystectomy has few effects on acid-base balance of electrolytes, nutritional metabolism and secretion of mucus.OBJECTIVE: To compare the clinical results of these two operations basis on long-term follow-up. DESIGN: Retrospective analysis.SETTING: Department of Urinary Surgery, the Second Affiliated Hospital of Kunming Medical College.PARTICIPANTS: 164 patients with carcinoma of bladder were selected from Department of Urinary Surgery, the Second Affiliated Hospital of Kunming Medical College form January 1995 to March 2005. Ninety-six of them, including 74 males and 22 females, with age of 43-74 years and the average age of 65 years, accepted the operation of orthotopic ileal neobladder were regarded as the ileal neobladder group, and the other 68, including 64 males and 4 females, with age of 51-72 years and the average age of 62 years, accepted the operation of orthotopic sigmoid neobladder were regarded as the sigmoid neobladder group. All patients were finally diagnosed as pathological examination, and informed consent was provided by all patients. Treatment plan was approved by the local ethical committee.METHODS: ① Orthotopic ileal neobladder: Once the bladder was removed, a segment of ileum about 40-60 cm in length was isolated. In the operative procedure, the distal part of ileum which connected to the caecum often kept, the length of which was 15-20 cm. Both distal ends of the ureters were anastomosed to the homolateral not been split end of the isolated bowel. A perforation was constructed at the bottom of the pouch which served as the outlet, this outlet was then anastomosed to the proximal portion of the remaining urethra. ② Orthotopic sigmoid neobladder: After surgically removing the bladder, a part of the sigmoid colon, the length of which was 30-40 cm was isolated. Other operations were as the same as those mentioned above. MAIN OUTCOME MEASURES: Time of operation, blood loss during the procedure, length of time confined to bed, time of indwelling catheter, the ability to maintain continence and urinate, the results of urodynamic studies, and pouch related complications after operation.RESULTS: In 164 patients, 12 (7.3%) were lost to follow-up. The mean follow-up times were 46 months in the group of orthotopic ileal neobladder and 42 months in the group of orthotopic sigmoid neobladder, respectively. Blood loss during the procedure and the ability to maintain continence and urinate were similar in the two groups (P > 0.05). Compared with sigmoid neobladder group, the ileal neobladder group spent more time on operation, keeping the bed and indwelling catheter. The max volume of ileal pouch was higher than that of sigmoid pouch, and the difference was significant in statistic analysis (t=2.56-3.08, P < 0.05-0.01). Incidence of complication of ileal pouch (16.7%, 29.2%) was higher than that of sigmoid pouch (9%, 16%). The incidence in the early phase was not significantly different, but that in the late phase was significantly different (x2=5.426, P < 0.05).CONCLUSION: Compared with orthotopic ileal neobladder, sigmoid neobladder is worthy of being preferred for its shorter operative time, faster recovery and lower rate of pouch related complications.

Objective To explore the treatment strategies for grade Ⅱ supination adduction ankle fracture. Methods From March 2003 to September 2008, 32 patients with grade Ⅱ supination adduction ankle fractures were treated surgically. There were 21 males and 11 females, at a mean age of 44.5 years (range, 21-76 years). Three patients had open ankle fractures. Anteromedial approach to the medial malleolus was taken to expose the vertical medial malleolus fractures and tibial plafond for exploring damage to distal articular surface of the tibia and that to cartilage of the talus. Open reduction and internal fixation with impaction of the articular fragment and possible bone grafting were applied to restore the height of the collapsed tibia. Medial mallcolus fractures were anatomically reduced and the intra-articular cartilage debris removed under direct vision. Repair of the lateral ligament injuries was decided acoording to the stability of the ligament. Different internal fixation was chosen according to fracture displacement of the block size and degree of lateral malleolus fractures. Fracture union, internal fixation and osteoarthritis were detected by X-ray examination. The range of ankle motion was measured. Maryland foot score was taken to assess the ankle function.Results Twenty-three patients were followed up postoperatively for a mean period of 27.9 months ( range, 6-47 months). Two prominent screws were removed from one patient five months after operation because of loosening. Bony fusion was achieved in all patients after an average period of 2.9 months ( range, 2.3-5.1 months). X-ray examination revealed no other internal fixation loosening or osteoarthritis. The average range of motion was 13 degrees of dorsiflexion (range, 6-17 degrees) and 36 degrees of plantarflexion (range, 27-46 degrees). According to Maryland foot score, ankle function was excellent in 19 patients and good in four, with excellence rate of 100%.Conclusions Understanding injury mechanism of supination adduction ankle fracture, strengthening the diagnosis and treatment of damage of tibial plafond articular surface height, cartilage and talar articular surface cartilage can effectively reduce the incidence of complications such as osteoarthritis. Anteromedial incision allows excellent exposure of the medial tibial plafond for clearance of intra-articular cartilage pieces, recovery of distal tibial articular surface height and placement of internal fixation.

Objective To explore the operative methods for the first metatarsal fractures. Methods From January 2003 to January 2006, surgical operation was done on 17 patients with the first metatarsal fractures including 15 males and two females at average age of 40.5 years (11-65 years). There were four patients with the first metatarsal base fractures, seven with the first metatarsal shift frac-tures and six with the first metatarsal neck or head fractures, of whom four were with open fractures. The surgical treatment included open reduction, plate internal fixation and screw or K-wire fixation. Results Of all, 14 patients were followed up for average 14 months ( 12-24 months), which showed wound healing at one stage, without any complications. The bone union time was 8-16 weeks (mean 10.5 weeks). All patients could walk with weight loading after mean 13 weeks (9-18 weeks), without obvious pain or com-plaints. According to the midfoot and forefoot scale of American Orthopedic Foot and Ankle Society (AOFAS), the mean score was 86.3 points (78-100 points). Conclusion Anatomic reduction and stable internal fixation is the best solution for the first metatarsal fracture and plays important role in recovery of foot form and foot arch function.

Clinical data of 53 patients with lower caliceal stone during August 2005 and March2007 were analyzed retrospectively.The stones were 11-35 mm in diameter.Under the guidance of X-ray.single renal tract parallel to the lower caliceal for percutaneous nephrolithotomy was established.The procedures were successful in all the patients.Fifty patients were stone free after first minimally invasive pereutaneous nephrolithotomy(MPCNL),2 were stone free following second MPCNL,1 saw residual small stones clear off spontaneously during the follow-up period.Operative time was 65-162 minutes.and blood loss was 10-200 ml.No severe complications or death occurred.MPCNL may be related with minimal invasion and fewer complications,thus provides an effective and safe way of lower caliceal stone treatment.

Objective To evaluate the surgical method and curative effect of minimally invasive percutaneous nephrolithotomy(MPCNL) in treatment of impacted proximal ureteric calculi.Methods 45 cases of proximal ureteric calculi treated with MPCNL were studied retrospectively.Percutaneous nephrostomy was established under the guide of X-ray,B-ultrasound and naked eye,and the nephropathy was extended to F16 through invasive percutaneous.Stones were taken out by ureteropyeloscopic pneumatic lithotripsy with help of hydraulic perfusion pump.Results The surgical time was 15～110 min with the average of 42 min after percutaneous nephrostomy.The average blood loss volume was 30 mL;no severe complications were occurred in the intra-or post-operative time.The rate of complete clearance of stones was 100% in first attempt.The mean hospital stay was 9 d,and the mean postoperative hospital stay was 3.5 d.Conclusion MPCNL used to treat the impacted proximal urethral calculi have satisfied effects and a lot of merits.

Objective To elucidate the diagnosis and treatment of the bladder mixed tumor.Methods 16 cases treated from Jun 1990 to Aug 2004 were reviewed.The clinical manifestations,diagnosis,treatment and prognosis were discussed.Correlative literature was reviewed at the same time.Results 16 cases of the bladder mixed tumor accounted for 6.9% of 223 bladder tumor patients in the same period,of which 7 of 16 were transitional squamous cell carcinoma,4 transitional adenocarcinoma,3 transitional squamous adenocarcinoma and 2 squamous adenocarcinoma mixed tumor.Most of the patients had irritable bladder symptoms and hematurine.Partial cystectomy was undergone for 3 of 16 cases,total cystectomy for 10 and radical total cystectomy for 3.The main treatment was partial or total cystectomy.The overall survival rates at 1,3 and 5 years post operation were 81.3%,56.3% and 12.5% respectively.Conclusion There were higher malignancy and worse prognosis in bladder mixed tumor.Early diagnosis and therapy might prolong survival.Radical total cystectomy seems to be the best method of treatment.

Objective To evaluate the effect of technical improvement of radical retropubic prostatectomy(RRP) for patients and reduction of complications.Methods 22 patients with clinically prostate cancer(mean age 67 years,stage B 19 cases,stage C 3 cases) underwent radical retropubic prostatectomy.During operation the dorsal vein complex,puboprostatic ligament,puborectalis sling,the neurovascular bundle,external urethral sphincter,reconstruction of the bladder neck were carefully managed.Results All the patients recovered uneventful except 2 deaths,and they survived and were followed up for a mean time of 16 months(range 1～4 years).The mean operative time was 140 minutes(range 90～220minutes) and the mean blood loss was 600mL(range 250～1500mL).16 cases received blood transfusion for 300～1200mL and no ureteral or rectal injury occurred.The urinary catheters were removed 2～3 weeks after operation.2 cases had stress incontinence 3 months later,1 case encountered urethral stricture and became well after urethral dilation,15 cases had satisfactory erectile function after operation and 3 patients had biochemical failure and endured continually chemotherapy during follow-up.Conclusions Accurate maneuver is handled according to correct anatomy can protect the apex of prostate and its surrounding tissue and reconstructing the bladder neck is helpful to reduce complications and achieve better outcome.

Objective To evaluate the surgical method and curative effect of minimally invasive percutaneous nephrolithotomy(MPCNL) in treatment of impacted proximal ureteric calculi and giant renal pelvic calculi with moderate or severe hydronephrosis by non-imaging in localization.Methods 52 cases of calculi treated with MPCNL were studied retrospectively.Percutaneous nephrostomy was established by non-imaging in localization(naked eye) according location of kidneys,length of 12th ribs,degree of hydronephrosis and condition of calculi,and the nephropathy was extended to F16 through invasive percutaneous.Stones were taken out by ureteropyeloscopic pneumatic lithotripsy with the help of hydraulic perfusion pump.Results The operative time was 32~140min with the average of 112min.The average blood loss volume was 45mL.No severe complication occurred in the intra-or post-operative time.The rate of complete clearance of stones was 96 % in first attempt,and the residual stones passed out by themselves after the double "J" tube was pulled out in cases.The mean hospital stay was 9 days,and the mean postoperative hospital stay was 4.2 days.Conclusion To treat the impacted proximal ureteric calculi and giant renal pelvic calculi with moderate hydronephrosis or severe hydronephrosis,some skilled doctors can appropriately use the method of MPCNL by non-imaging in localization,since the method can reduce the harm by X-ray,and save medical expenses.