[Transurethral resection in prostate cancer, a radical procedure. Experience with 1017 cases]. / Resección transuretral en cáncer de próstata, un procedimiento radical. Experiencia con 1017 casos.

OBJECTIVES: From the beginning of TUR in 1931 the reseccionists thought of resecting prostate cancer. Execution however failed for deficient instruments and techniques. The first transurethral resection for prostate cancer: TURPC--was performed at our institution in 1957 by Hans J. Reuter. Low pressure irrigation enabled safe transurethral resection of the prostate including the capsule. Thus we started in 1985 a prospective study to verify TURPC as a radical procedure. METHOD: TURPC requires continuous low pressure irrigation with irrigating reservoir fixed at the operating table. The liquid level within is to maintain less than 20 cm. water above the pubic region in lithotomy position. Continuous flow is maintained by suprapubic trocar and a resectoscope with 28Fr. sheath. An autoregulated electro-surgical unit is indispensable. It automatically adjusts the high-frequency current to suit the cut tissue's electrical resistance for precise cutting. Videomonitoring is mandatory. The prostate is resected completely with its capsule into periprostatic fat together with the seminal vesicles. The specimen is retrieved in fractions to guarantee correct histopathological staging. If indicated laparoscopic staging lymphadenectomy is performed. A secondary session for control of positive margins follows after 12 weeks. RESULTS: From 1985-2004 1,017 patients with a mean age of 68.9 years and with clinically localized prostate cancer were resected by 5 surgeons with curative intention. The cancer stage distribution was in %: T1: 12, T2: 43, T3: 41, T4: 4.--G1: 8, G2: 72, G3: 20. Mortality 1 out of 1,017. Bladder neck incision 8.9%. Incontinence grade 3: none. Postoperative survival over 10 years was 82% in T1, 87% in T2, 81% in T3 and 34% in T4 patients. Biochemical recurrence as of the rise of three consecutive PSA-values was within 5 years 15% in T1, 19% in T2, 27% in T3. CONCLUSIONS: Considering our results we conclude that prostate cancer can be resected transurethrally as radical as with open surgery. The outcome as to survival and PSA-recurrence is comparable, the incontinence rate is less then with open surgery. It is mandatory to have low pressure irrigation with suprapubic trocar, 28Fr. sheath and on autoregulated electrosurgical unit, video monitoring and a well experienced reseccionist.

Resección transuretral en cáncer de próstata, un procedimiento radical. Experiencia con 1017 casos / Transurethral resection in prostate cancer, a radical procedure. Experience with 1017 cases

Objetivo: Desde el comienzo de la resección transuretral RTU en 1931 el reseccionista siempre tuvo en mente resecar el cáncer de próstata. Sin embargo, su práctica no tuvo éxito por deficiencias instrumentales y técnicas. La primera resección transuretral por cáncer de próstata RTUPC se llevó a cabo en nuestra Institución en 1957 por Hans J. Reuter. La irrigación a baja presión permitió una resección segura de la próstata incluyendo la cápsula. De esta forma iniciamos en 1985 un estudio prospectivo para verificar si la RTUPC era un procedimiento radical. Métodos: La RTUPC requiere una irrigación continua a baja presión con el reservorio de líquido anclado a la mesa de operaciones. El nivel de líquido debe mantenerse por debajo de 20 centímetros respecto a la región púbica en posición de litotomía. El flujo continuo con un trocar suprapúbico y un resectoscopio con vaina de calibre 28 Ch. Es indispensable una unidad de electro-bisturí autorregulada para adecuar la corriente de alta frecuencia a la resistencia al corte de los tejidos a resecar para que este sea preciso. El video monitoreo es obligado. La próstata se reseca completamente con su cápsula y algo de la grasa periprostática así como las vesículas seminales. Las muestras de tejido son etiquetadas por grupos para garantizar un correcto estadiaje histopatológico. Si la linfadenectomía laparoscópica está indicada, esta se llevará a cabo. A las 12 semanas se practica una segunda sesión de control de márgenes positivos. Resultados: Desde 1985 al 2004, 1017 pacientes con una media de edad de 68,9 años y cáncer de próstata localizado fueron resecados por 5 cirujanos diferentes con intención curativa. El porcentaje de estadios cancerosos fue de T1: 12, T2: 43, T3: 41, T4: 4. El grado de G1: 8, G2: 72, G3:20. La mortalidad fue de 1 sobre 1017. Precisaron de incisión de cuello vesical el 8,9%. Incontinencia grado 3: Ninguno. La supervivencia postoperatoria a los 10 años fue del 82% en los T1, 87% en los T2, 81% en los T3 y del 34% en los T4. La recidiva bioquímica definida como el aumento de tres valores consecutivos del PSA sin limite inferior, fue en 5 años del 15% en los T1, 19% en los T2 y 27% en los T3. Conclusiones: Considerando nuestros resultados, concluimos que la Resección Transuretral del Cáncer de Próstata (RTUPC) es tan radical como la cirugía abierta. Los resultados de supervivencia y la recidiva del PSA son comparables, la tasa de incontinencia es mas baja que con la cirugía abierta. Es obligatoria la irrigación a baja presión utilizando el trocar suprapúbico, vaina del 28 Ch. y un electrobisturí autorregulado, la videomonitorización y un reseccionista con experiencia (AU)

Objectives: From the beginning of TUR in 1931 the reseccionists thought of resecting prostate cancer. Execution however failed for deficient instruments and techniques. The first transurethral resection for prostate cancer: TURPC - was performed at our institution in 1957 by Hans J. Reuter. Low pressure irrigation enabled safe transurethral resection of the prostate including the capsule. Thus we started in 1985 a prospective study to verify TURPC as a radical procedure. Method: TURPC requires continuous low pressure irrigation with irrigating reservoir fixed at the operating table. The liquid level within is to maintain less than 20cm. water above the pubic region in lithotomy position. Continuous flow is maintained by suprapubic trocar and a resectoscope with 28Fr. sheath. An autoregulated electro-surgical unit is indispensable. It automatically adjusts the high-frequency current to suit the cut tissue’s electrical resistance for precise cutting. Videomonitoring is mandatory. The prostate is resected completely with its capsule into periprostatic fat together with the seminal vesicles. The specimen is retrieved in fractions to guarantee correct histopathological staging. If indicated laparoscopic staging lymphadenectomy is performed. A secondary session for control of positive margins follows after 12 weeks. Results: From 1985-2004 1017 patients with a mean age of 68.9 years and with clinically localized prostate cancer were resected by 5 surgeons with curative intention. The cancer stage distribution was in %: T1: 12, T2: 43, T3: 41, T4: 4. -G1: 8, G2: 72, G3: 20. Mortality 1 out of 1017. Bladder neck incision 8.9%. Incontinence grade 3: none. Postoperative survival over 10 years was 82% in T1, 87% in T2, 81% in T3 and 34% in T4 patients. Biochemical recurrence as of the rise of three consecutive PSA-values was within 5 years 15 % in T1, 19 % in T2, 27 % in T3. Conclusions: Considering our results we conclude that prostate cancer can be resected transurethrally as radical as with open surgery. The outcome as to survival and PSA-recurrence is comparable, the incontinence rate is less then with open surgery. It is mandatory to have low pressure irrigation with suprapubic trocar, 28Fr. sheath and an autoregulated electrosurgical unit, video monitoring and a well experienced reseccionist (AU)

[Development and usage of a new laser resectoscope]. / Zur Entwicklung und Anwendung eines neuen Laserresektoskops.

BACKGROUND: Endoscopes for the application of laser energy have not been modified substantially for 3 decades. They have two essential disadvantages: the laser probe has no sufficient fixation and irrigation is ineffective in clearing endoscopic vision from hemorrhage. These defects were corrected in cooperation with the R. Wolf Company when developing a new laser resectoscope. In addition the one-handed usage was improved. MATERIAL AND METHOD: The new instrument was used in 71 of the 329 patients undergoing surgery of the prostate with KTP laser by 8 surgeons in our institution. No instrument has been damaged by laser since. Seven of eight surgeons have acknowledged the advantages and approved the new laser endoscope. CONCLUSION: The new laser resectoscope can be recommended to improve the safety of endoscopic laser surgery in general.

La vaporización fotoselectiva del adenoma prostático con el ktp-láser (kalium-titanyl-phosphat) de 80 watt y la RTU-P de baja presión hidráulica / The photoselective vaporization of prostate adenoma with the 80 watt ktp-laser (kalium-titanyl-phosphat) and the low hydraulic pressure tur-p

El objetivo de este trabajo prospectivo es determinar la eficacia del método KTP-láser de 80 watt para la vaporización y ablación de la HPB sintomática. También se analizan los resultados al combinar el KTP-láser con la RTU-P y su repercusión sobre la hemoglobina. Material y Método: 300 pacientes con HPB sintomática fueron tratados entre agosto del 2004 y noviembre del 2006 con el KTPláser o combinado con RTU-P. La resección adicional fue efectuada en pacientes con adenomas grandes o por lóbulo medio acentuado. El efecto ablativo fue controlado al final de la operación por medio de TRUS. Resultados: 300 pacientes fueron tratados en 2 grupos. El grupo 1 (n: 50) con sólo tratamiento láser y pequeños adenomas, la hemoglobina se redujo un 3,2 por ciento y nadie requirió una transfusión. El grupo 2 (n: 250) con tratamiento combinado de KTP-láser y RTU-P en adenomas grandes, la hemoglobina se redujo en promedio 15,2 por ciento después de la intervención; 2 pacientes (0,8 por ciento) necesitaron una transfusión. Conclusión: El estudio pone de manifiesto, las ventajas de combinar ambos procedimientos quirúrgicos para obtener un mejor resultado en la ablación del adenoma sobre todo en próstatas de gran tamaño.

The objective of this prospective study is to determine the effectiveness of the 80 watt KTP laser method for the vaporization and ablation of the symptomatic BPH. Also the results when combining the KTP-laser with the TUR-P and their repercussion on the haemoglobin are analysed. Material and Method: 300 patients with symptomatic BPH were treated between august 2004and november 2006 with the KTP-Laser or combined with TUR-P. The additional Resection was carried out in those patients with great adenomas or to have accentuated middle lobule. The ablative effect was controlledat the end of the operation with TRUS (transrectal ultrasound). Results: 300 patients were treated in 2 groups. The group 1 (n: 50) just by laser treatment and small adenomas, the haemoglobin was reduced a 3.2 percent and nobody required a transfusion. Group 2 (n: 250) with combined treatment of KTP-laser and TURP in great adenomas, the haemoglobin was reduced in average 15,2 percent after the intervention; 2 patients (0,8 percent) needed a transfusion. Conclusion: Our study puts of open, the advantages to combine both surgical procedures to mainly obtain a better result in the ablation of the prostate adenoma in prostates of great size.

[The low hydraulic pressure transurethral resection of the prostate results in 340 patients with great adenomas]. / La resección transuretral de la próstata de baja presión hidráulica, resultados en 340 pacientes con adenomas grandes.

INTRODUCTION: the transurethral resection of prostate TURP is the elective treatment for the small and medium adenomas. In this study they analyse the effectiveness, the results and the postoperative morbidity in the resection of the great adenomas. PATIENTS AND METHOD: We study 340 patients with great adenomas and symptomatic infravesical obstruction that were operated with the low hydraulic pressure RTUP between August of 1999 and June of 2006. RESULTS: Average Age of the patients 69 years (range 51-89). Prostate volume by TRUS, 107 ml (70-204). PSA 7,94 ng/ml (0,71-26,4). Weight of the resected fragments: 74,5gr. (50-160), time of the intervention 65 min. (35-155), postoperative urethral catheterisation 1.7 days (1-8), suprapubic derivation 6.5 days (5-15), the duration of hospital stay after surgery were 8 days (7-16), peak flow pre-op. 11.2 ml/sec. (5-15,7), post-operative 19.7 ml/sec. (7-41,3). There were no cases of TURP syndrome in this group. Operative complications: Urinary infection without fever (bacteria >100.000) 95 patients (27.9%), bladder derivation by preoperative urinary retention 53 patients (15,6%). 18 patients (5,3%) with postoperative urinary retention. 11 patients (3,2%), with infection and fever >38 degrees C. 7 patients (2%) with postoperative bladder bleeding, 2 patients (0,6%) with urethral lesion. 1 patient (0.3%), with massive scrotal hematoma (after vasectomy). Control of the pre and post operative hemoglobin: Hemoglobin pre-op 15 g/dl (12-19,3), hemoglobin post-op 11,5 g/dl (7,6-16,4), difference of (- 3,5g/dl) 23,3%. In only 29 patients (8.5%) it was necessary to carry out a sanguineous transfusions (heterolog) of 2 to 4 EC (500 ml), the TRUS was 125 ml, weight of the fragments 90 gr. (52-140), the hemoglobin pre-op was 14,72g/dl and post-op of 8,8g/dl with a difference of (- 5,92g/dl) 40.2%. CONCLUSIONS: The video assisted low hydraulic pressure TURP, is an effective method in the surgical treatment of great prostate adenomas. The severe postoperative complications are little, and in 311 patients (91.5%) it was not necessary sanguineous transfusion. The stationary treatment and the urethral catheterisation is smaller in comparison with the open adenomectomy.

La resección transuretral de la próstata de baja presión hidráulica, resultados en 340 pacientes con adenomas grandes / The low hidraulic pressure transurethral resection of the prostate results in 340 patients with great adenomas

Introducción: La resección transuretral de próstata (RTUP) es el tratamiento electivo para los adenomas pequeños y medianos. En este trabajo se analizan la efectividad, los resultados y la morbilidad peri-operatoria en la resección de los adenomas grandes. Pacientes y método: Se analizan los resultados de 340 pacientes con adenomas grandes y obstucción infravesical sintomática que fueron operados con la RTUP de baja presión hidráulica entre agosto de 1999 y junio del 2006. Resultados: Edad promedio de los pacientes 69 años (rango 51-89). Volumen prostático por TRUS, 107 ml (70-204). PSA 7,94ng/ml (0,71-26,4). Peso de los fragmentos resecados: 74,5gr (50-160), tiempo de RTUP 65 min. (35-155), sondaje uretral postoperatorio 1,7 días (1-8), sondaje suprapúbico 6,5 días (5-15), estancia hospitalaria 8 días (7-16), flujometría máx. preoperatoria 11,2 ml/seg. (5-15,7), postoperatoria 19,7 ml/seg. (7-41,3). En ningún caso de este grupo se observó el síndrome de RTUP. Complicaciones operatorias: Infección urinaria sin fiebre (Bac. >100.000) 95 pac. (27,9%), sondaje vesical por retención urinaria pre-operatoria 53 pac. (15,6%), retención urinaria post-operatoria 18 pac. (5,3%), infección urinaria con fiebre >38°C 11 pac. (3,2%), tamponamiento vesical por sangrado post-operatorio 7 pac.(2%), falsa vía en 2 pac. (0,5%), hematoma escrotal masivo (luego de vasectomia) en 1 pac. (0,3%). Control de la hemoglobina pre y postoperatoria: Hb pre-op 15 g/dl (12-19,3), Hb post-op 11,5 g/dl (7,6-16,4), diferencia (- 3,5g/dl) 23,3%. En sólo 29 pacientes (8,5%) fue necesario efectuar una transfusión sanguínea (heteróloga) de 2 a 4 bolsas (500ml c/u), la TRUS fue de 125 ml, el tejido resecado 90 g (52-140), la Hb preoperatoria fue de 14,72g/dl y la post-op de 8,8g/dl con una diferencia de (-5,92g/dl) 40,2%. Conclusiones: La RTUP vídeo-asistida de baja presión hidráulica, es un método efectivo en el tratamiento quirúrgico en adenomas prostáticos grandes. Las complicaciones postoperatorias severas son escasas, y en 311 pacientes (91,5%) no fue necesaria ninguna transfusión sanguínea. La estancia hospitalaria así como el sondaje uretral son menores en comparación con la adenomectomía abierta

Introduction: the transurethral resection of prostate TURP is the elective treatment for the small and medium adenomas. In this study they analyse the effectiveness, the results and the postoperative morbidity in the resection of the great adenomas. Patients and Method: We study 340 patients with great adenomas and symptomatic infravesical obstruction that were operated with the low hydraulic pressure RTUP between August of 1999 and June of 2006. Results: Average Age of the patients 69 years (range 51-89). Prostate volume by TRUS, 107 ml (70-204). PSA 7,94 ng/ml (0,71-26,4). Weight of the resected fragments: 74,5gr. (50-160), time of the intervention 65 min. (35-155), postoperative urethral catheterisation 1.7 days (1-8), suprapubic derivation 6.5 days (5-15), the duration of hospital stay after surgery were 8 days (7-16), peak flow pre-op.11.2 ml/sec. (5-15,7), post-operative 19.7 ml/sec. (7-41,3). There were no cases of TURP syndrome in this group. Operative complications: Urinary infection without fever (bacteria >100.000) 95 patients (27.9%), bladder derivation by preoperative urinary retention 53 patients (15,6%). 18 patients (5,3%) with postoperative urinary retention. 11 patients (3,2%), with infection and fever >38°C. 7 patients (2%) with postoperative bladder bleeding, 2 patients (0,6%) with urethral lesion. 1 patient (0.3%), with massive scrotal hematoma (after vasectomy). Control of the pre and post operative hemoglobin: Hemoglobin pre-op 15 g/dl (12-19,3), hemoglobin post-op 11,5 g/dl (7,6-16,4), difference of (- 3,5g/dl) 23,3%. In only 29 patients (8.5%) it was necessary to carry out a sanguineous transfusions (heterolog) of 2 to 4 EC (500ml), the TRUS was 125 ml, weight of the fragments 90 gr. (52-140), the hemoglobin pre-op was 14,72g/dl and post-op of 8,8g/dl with a difference of (- 5,92g/dl) 40.2%. Conclusions: The video assisted low hydraulic pressure TURP, is an effective method in the surgical treatment of great prostate adenomas. The severe postoperative complications are little, and in 311 patients (91.5%) it was not necessary sanguineous transfusion. The stationary treatment and the urethral catheterisation is smaller in comparison with the open adenomectomy

[Combined treatment of prostatic adenoma with the 80 Watt KTP-laser and low-pressure transurethral resection]. / Tratamiento combinado del adenoma prostático con el KPT-láser de 80 Watt y la resección transuretral de baja presión.

INTRODUCTION: The purpose of this prospective study is to determine the effectiveness of method for vaporisation and elimination of the prostate adenoma. The results are analysed that obtain when combining this Laser-method with the resection at low pressure. MATERIAL AND METHOD: 151 patients with BPH symptomatic were treated between August 2004 and january 2006 with the KTP-Laser or combined with low pressure TURP. The additional Resection was carried out in those patients with large adenomas or to have accentuated middle lobule. The ablative effect was controlled at the end of the operation with TRUS (transrectal ultrasound). RESULTS: 151 patients were divided in 2 groups, group 1 (n:43) those with single laser treatment and group 2 (n: 108) with combined treatment. The control of the post-miccional peak-flow demonstrates an increase of 65,6% in group 1, and of 122,4 % in group 2. CONCLUSION: Our study reveals the advantages of combining both operative procedures to mainly obtain a better result in the ablation of the prostate adenoma in prostates of great size.

El tratamiento del adenoma protático sintomático con el KPT-Láser de 80 watt y la resección transuretral de baja presión / Treatment of symptomatic prostatic adenoma with the laser-KTP of 80 watt and transurethral resection of low presure

Introducción: La finalidad de este trabajo prospectivo es determinar la eficacia del método KTP-láser para la vaporización y eliminación del adenoma prostático. Se analizan también los resultados que se obtienen al combinar el método KTP-láser de 80 watt con la RTUP de baja presión. Material y métodos: 225 pacientes con HBP sintomática fueron tratados entre agosto del 2004 y mayo del 2006 con el KTP-láser o combinado con RUTP a baja presión. La resección adicional fue efectuada en aquellos pacientes con adenomas grandes o por tener el lóbulo medio acentuado. El efecto ablativo fue controlado al final de la operación por medio de TRUS (sonografía prostática transrectal). Resultados: 225 pacientes tratados en 2 grupos, el grupo 1 (n:50) aquellos con solo tratamiento láser, sobre todo pequeños adenomas y el grupo 2 (n:175) con tratamiento combinado de KTP-láser y RTUP a baja presión en adenomas grandes. La flujometría máxima demuestra una mejoría del 44, 5 porciento en el grupo 1 entre antes y después del tratamiento, en el grupo 2 la diferencia es de 122, 4 porciento. Conclusión: Nuestro estudio pone de manifiesto las ventajas de combinar ambos procedimientos quirúrgicos para obtener un mejor resultado en la ablación del adenoma prostático, sobre todo en próstatas de gran tamaño(AU)

El tratamiento del adenoma protático sintomático con el KPT-Láser de 80 watt y la resección transuretral de baja presión / Treatment of symptomatic prostatic adenoma with the laser-KTP of 80 watt and transurethral resection of low presure

Introducción: La finalidad de este trabajo prospectivo es determinar la eficacia del método KTP-láser para la vaporización y eliminación del adenoma prostático. Se analizan también los resultados que se obtienen al combinar el método KTP-láser de 80 watt con la RTUP de baja presión. Material y métodos: 225 pacientes con HBP sintomática fueron tratados entre agosto del 2004 y mayo del 2006 con el KTP-láser o combinado con RUTP a baja presión. La resección adicional fue efectuada en aquellos pacientes con adenomas grandes o por tener el lóbulo medio acentuado. El efecto ablativo fue controlado al final de la operación por medio de TRUS (sonografía prostática transrectal). Resultados: 225 pacientes tratados en 2 grupos, el grupo 1 (n:50) aquellos con solo tratamiento láser, sobre todo pequeños adenomas y el grupo 2 (n:175) con tratamiento combinado de KTP-láser y RTUP a baja presión en adenomas grandes. La flujometría máxima demuestra una mejoría del 44, 5 porciento en el grupo 1 entre antes y después del tratamiento, en el grupo 2 la diferencia es de 122, 4 porciento. Conclusión: Nuestro estudio pone de manifiesto las ventajas de combinar ambos procedimientos quirúrgicos para obtener un mejor resultado en la ablación del adenoma prostático, sobre todo en próstatas de gran tamaño

Prostatic hyperplasia over 80 grams weight, is transurethral resection an adequate procedure? Results of a prospective study.

A prospective study of transurethral resection with continuous low pressure irrigation was undertaken to find out, whether large prostates can be operated transurethrally without undue risk. Since 1986, the beginning of the study, 121 prostates with adenomas over 80 grams weight (> 80 g group) were resected. The mean age of the patients was 70.1 years, the mean weight of the resected prostate tissue was 104 grams in 66 minutes. The postoperative mortality was below 1% (1 patient). 17 patients (14%) needed blood transfusion, 11 patients had peroperative hemodilution. Even with large prostate, considering the rather high mean age of the patients treated, there is no considerably elevated operating risk, when large prostates are resected transurethrally. It however has to be emphasized, that this is achieved only with continuous low pressure irrigation and the loop of a 28 Fr. standard resectoscope in combination with an automatically regulated electrosurgical unit.

[Total transurethral electroresection of carcinoma of the prostate]. / Electrorresección transuretral total del carcinoma de la próstata.

Transurethral resection of the prostatic carcinoma was performed here most completely at a time already when radical surgical prostatectomy was not a rather new procedure. The preliminary evaluation of 150 cases of all stages (T1-4) showed a 5 year survival rate of almost 80% with post-operative complications comparable to transurethral prostatectomy of the adenoma.

[Transurethral low pressure prostatectomy. Technic, blood loss and water syndrome]. / Die transurethrale Niederdruckprostatektomie. Technik, Blutverlust und Wassersyndrom.

The new procedure for transurethral prostatectomy (TURP with physiologic low pressure irrigation and continuous aspiration of irrigant) reduces complication and mortality in respect to surgical prostatectomy: In 2.500 TURP clinical significant pulmonary embolism was not realised, mortality was 0.3%. The average blood loss was 238 cc. by a weight of 44.8 g, blood transfusion were necessary in only 4%. Low pressure TURP can be performed in most high risk patients, this is not true for open surgical prostatectomy, which has a rate of complications up to 25%. Postoperative recovery and late results are definitely improved by low pressure TURP, teaching is facilitated.

[Complete separation of the cavernous bodies with penis deviation--an epispadias equivalent]. / Komplette Schwellkörperseparation mit Penisdeviation--ein Epispadieäquivalent.

The presented case report describes the not-yet-published existence of an epispadia equivalent, which consists of the complete separation of both cavernous bodies associated with both an atypical location of the urethral orifice on the dorsal site of the glans and a considerable ventral deviation of the penis. This separation was simultaneously associated with a unilateral arterialization of the whole penis via the right internal pudendal artery. The patient complained about an inadequate sexual performance, which was due to a marked ventral penile curvature requiring surgical correction. The operative approach included not only a corporoplasty, but also a complicated fusion of the cavernous bodies, accomplished by a fenestration and subsequent anastomosis. The result was cosmetically and functionally optimal.