ČESKÁ UROLOGIE / CZECH UROLOGY – 1 / 2021

67 KAZUISTIKY Ces Urol 2021; 25(1): 62–68 gain sufficient lenght, we decided to perform a suprapubic lipectomy and complete suspenso‑ ry ligament division. The body mass index of out patient was 35, with the typical fat tissue deposit in the prepubic region. At this point, a testicular prosthesis (Polytech Health and Aesthetics/Ger‑ many 2×2.2 cm) was implanted in the prepubic space, to prevent adhesion of disconnected sus‑ pensory ligaments (Fig. 3C). Next stage of our reconstruction included pe‑ nile fixation with so called „tacking sutures“ (Vicril 4.0) between the tunica albuginea of the penile shaft base and edges of subdermal dartos of ab‑ dominal skin to prevent retraction of the penis. This manoeuvre allows formation of the penoscro‑ tal and penopubic angle. The urethral flap was inspected and left intact, the margins served as the neo‑sulcus border. The final step was aimed to correct the total penis shaft skin defect, which was substituted with STSG. The graft was typically harvested from the upper left lateral thigh using a pneumatic dermatome (at a thickness 0.4 mm, size of the graft was 9×7 cm). The skin graft was meshed at the ratio of 1:1.5 (Fig. 3D, E). The graft was sutured at the critical areas around the penis base, neo‑sulcus with a running Saphilquick 4.0 suture. Consequently, quilting sutures were used to enhance the overall adherence and optimal graft take. Saphilquick 4.0 interrupted sutures were placed between the graft and superficial part of the tunica albuginea to improve the stabilization. The graft was covered with 1 layer of nonadhering dressing (JENONET‑Paraffin gauze), followed by the „tie‑over dressing“ bolster placement. Penis shaft was wrapped within, and two bolsters were sutured together in order to maintain compression. (Fig. 3F). We routinely tend to leave the dressing for 5 days (Fig. 3K, L) in situ either for scrotal, penile shaft grafting or glans resurfacing cases. The harvested areawasmanagedwith the appli‑ cation of Biatain silicone bolster (10×20 cm, Coloplast/ Austria) and the negative pressure V.A.C therapy (KCI Medical, Austria). The pressure was set to -50mmHg for 72 hours in the first phase (Fig. 3G, H). Thereafter the wound was evaluated for secretion, initial gra‑ nulation, oedema, and degree of erythema around themargins (Fig. 3I). When thewound secretionwas limited, we applied OpSite‑Post‑OP‑VISIBLE (10×20 cm, Smith &Nephew‑Austria) waterproof adhesive transparent dressing on the 4 th postoperative day, which allowed us continuous inspection of the area. Two days later, we left the wound open. Topical ad‑ ministration of Vaselinemixtedwith Baneocin cream (Bacitracin/Neomycin) was recommended for the next 7–10 days for the harvested and grafting area. Strict bed rest was advised for 3 days. As a thrombo‑ prophylactic measure Enoxaparin‑Natrium (Sanofi­ ‑Aventis‑Austria; 40mg subcutaneously) was started the evening after the operation. Broad spectrum second generation cephalosporin (Cefuroxim 1.5 g) twice dailywas administered for next 5 days. Urethral catheter CH 14 was left in situ for 10 days. The next abdominal CT scan was performed 3 and 6 months postoperatively with negative result. the patient was also advised to further check the neo‑glans as well as inguinal region. DISCUSSION Short term follow‑up (6 months) revealed, that we were able to achieve acceptable voiding as well as sexual functioning (self stimulation and oral inter‑ course). However due to the relative short penis, boli nazvájom fixované sutúrami, aby vytvárali dostatočnú kompresiu za účelom ideálnej adherencie štepu. V oblasti kritickýchmiestboli naloženédodatočnéfixačnéstehy.Dressingbol ponechaný intaktnýpodobu5dní.G,H) Kontinuálny podtlakovýdressingnamiesteodberu štepubol udržiavanýna tlakovýchhodnotách51mmHg (VAC–VacuumAssisted Closure, KCI; KineticConcept; Rakúsko) podobu5dní. Pacientmal indikovaný kľudna lôžku. I) 3. pooperačnýdeň – miesto odberu. J) 7. pooperačný deň – miesto odberu, pozorovať takmer kompletnú granuláciu spodiny, po dvoch cykloch VAC počas3dní a jedendeňbezVACsystému. K, L) Týždeňpozákrokupozorovať vitálny transplantát, bezakýchkoľvekprízna- kov zápalualebo ischemickýchzmien.M)Dva týždnepooperácii pozorovať ideálneujatie štepuaznámkykonečnej fázy epitelializácie. N) Objektívny nález po2mesiacoch