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18 August 2019, Volume 51 Issue 4
  • Review of upper urinary modified minimal invasive surgical technology
    Guang-pu DING,Si-da CHENG,Dong FANG,Kun-lin YANG,Xue-song LI,Hui-xia ZHOU,Qian ZHANG,Xiong-jun YE,Li-qun ZHOU
    2019, (4):  610-614.  doi: 10.19723/j.issn.1671-167X.2019.04.002    
    Abstract ( 29 )   HTML ( 4 )   PDF (1117KB) ( 21 )   Save
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    Upper urinary surgery is an important area of urology surgery. Open surgery used to be the gold standard of upper urinary surgery. With the development of medical techniques, minimal invasive surgeries including laparoscopic and robot assisted-laparoscopic surgery have gradually replaced the open surgery. Because of the complexity and diversity of upper urinary diseases, surgeries sometimes are difficult, and minimal invasive surgeries require higher surgical abilities of urologists than open surgeries. In recent years, depending on our surgical experience and international reports, our team from three Chinese medical centers summarizes techniques of upper urinary minimal invasive surgeries. For malignant diseases, such as renal and ureteral carcinomas, it’s important to totally remove the tumor first, and then to avoid the surgical injuries. We summarize surgical experience of retroperitoneal laparoscopic partial nephrectomy for moderately complex renal hilar tumors. Our team modified minimal invasive techniques for some complex tumors, including ring suture technique for renal hilar tumors, internal suspension technique for renal ventral tumors, and combination retroperitoneal laparoscopic surgery with mini-flank incision for complex renal tumors. While for begin diseases, urologists should focus on the resections and surgical injuries at the same time. We have reported the novel technique of laparoscopic aspiration for central renal angiomyolipoma, making the surgery simple and available. For reconstruction surgeries, operations should be based on several principals. We generalize it as “4TB principals”, which include “tension-free”, “water-tight”, “thin suture”, “no touch of the key area” and “protecting the blood supply”. Depending on the localization, length, and etiology of the strictures, different techniques are required. Our team summarize the pyeloplasty, ureteral reimplantation and ileal ureter replacement based on our surgical experience. For infant upper urinary surgeries, our team has made invasive surgeries that can be used in complex diseases, such as duplex kidney. Based on years of surgical techniques, our modified surgeries achieve a better subjective cosmetic result than the traditional surgeries. In the future, the standardized, practical, simple and individual minimal invasive surgical technique will become the main direction in the future researches.

    Construction of prognostic model and identification of prognostic biomarkers based on the expression of long non-coding RNA in bladder cancer via bioinformatics
    Fei-long YANG,Kai HONG,Guo-jiang ZHAO,Cheng LIU,Yi-meng SONG,Lu-lin MA
    2019, (4):  615-622.  doi: 10.19723/j.issn.1671-167X.2019.04.003    
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    Objective: To construct the prognostic model and identify the prognostic biomarkers based on long non-coding RNA (lncRNA) in bladder cancer.Methods: The lncRNA expression data and corresponding clinical data of bladder cancer were collected from The Cancer Genome Atlas (TCGA) database. The software Perl and R, and R packages were used for data integration, extraction, analysis and visualization. Detailly, R package “edgeR” was utilized to screen differentially expressed lncRNA in bladder cancer tissues compared with the normal bladder samples. The univariate Cox regression and the least absolute shrinkage and selection operator (Lasso) regression were performed to identify key lncRNA that were utilized to construct the prognostic model by the multivariate Cox regression. According to the median value of the risk score, all patients were divided into the high-risk group and low-risk group to perform the Kaplan-Meier (K-M) survival curves, receiver operating characteristic (ROC) curve and C-index, estimating the prognostic power of the prognostic model. In addition, the hazard ratio (HR) and 95% confidence interval (CI) of each key lncRNA were also calculated by the multivariate Cox regression. Moreover, we performed the K-M survival analysis for each significant key lncRNA from the result of the multivariate Cox regression.Results: A total of 691 lncRNA were identified as differentially expressed lncRNA, and 35 lncRNA signatures were initially considered associated with the prognosis of bladder cancer, where in 23 lncRNA were identified as key lncRNA associated with the prognosis. The overall survival time in years of the low-risk group was obviously longer than that of the high-risk group [(2.85±2.72) years vs. (1.58±1.51) years, P<0.001]. The area under the ROC curve (AUC) was 0.813 (3-year survival) and 0.778 (5-year survival) respectively, and the C-index was 0.73. In addition, HR and 95%CI of each key lncRNA were calculated by the multivariate Cox regression and 11 lncRNA were significant. Furthermore, K-M survival analysis revealed the independent prognostic value of 3 lncRNA, including AL589765.1(P = 0.004), AC023824.1(P = 0.022)and PKN2-AS1(P = 0.016).Conclusion: The present study successfully constructed the prognostic model based on the expression level of 23 lncRNA and finally identified one protective prognostic biomarker AL589765.1, and two adverse prognostic biomarkers including AC023824.1 and PKN2-AS1 in bladder cancer.

    Clinical and pathological analysis of small renal cell carcinoma
    Xiao-peng ZHANG,Zi-xiong HUANG,Lu-ping YU,Xiao-wei ZHANG,Qing LI,Shi-jun LIU,Tao XU
    2019, (4):  623-627.  doi: 10.19723/j.issn.1671-167X.2019.04.004    
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    Objective: To analyze the clinical and pathological features of small renal cell carcinoma (RCC), especially of those with diameter less than 4 cm and to understand the characteristics and factors related to recurrence and progression.Methods: A total of 200 patients with RCC were stratifiedly selected for retrospective analysis. Their baseline demographic features, tumor-specific clinical features, pathological features of renal lesions, especially microscopic features were collected. The patients were divided according to the largest diameter of renal tumor lesions. Univariate analysis was used to compare the differences between tumor staging and microscopic pathological features between the groups. Binary multivariate Logistic regression was used to investigate factors related to tumor progression and prognosis in the patients with small RCC.Results: The tumor diameters of 127 RCC patients were less than 4 cm and most of them had clear cell renal cell carcinoma (ccRCC). The increase in tumor diameter resulted in significantly higher T stage (P<0.01), higher WHO/International Society of Urological Pathology (ISUP) grade (P<0.05) and increasing chance of lymph node metastasis (P<0.01). Even when the tumor diameter was less than 4 cm, the patients might still have perirenal fat invasion, renal sinus invasion and greater elevated tumor grade (greater than grade 3) and synchronous lung metastasis. The incidences of intravascular thrombus (9.3% vs. 0) and tumor necrosis (27.8% vs. 5.5%) in the patients with RCC between 4-7 cm were significantly higher than those with RCC less than 4 cm (P<0.01). Sub-group analysis of small RCC (less than 4 cm) indicated that the patients with RCC between 2-4 cm were more likely to have intratumoral hemorrhage (44.7% vs. 23%, P<0.05) and necrosis than those with RCC less than 2 cm (8.2% vs. 0, P=0.095). Logistic regression analysis of small RCC showed that the incidence of tumor invasion to renal capsule was higher in ccRCC (OR=5.15, 95%CI: 1.36-19.52). Necrosis was closely related to the formation of peritumor pseudocapsule in small RCC (OR=14.90, 95%CI: 1.41-157.50). Increase in the tumor diameter was related to higher tumor grade (greater than grade 3) (OR=3.49, 95%CI: 1.11-10.93).Conclusion: The tumor stage and grade of small RCC (less than 4 cm) are low, but extra-renal invasion and synchronous distant metastasis may occur. Internal hemorrhage and necrosis in tumor, ccRCC subtype, along with microscopic features, such as the renal capsule invasion and perirenal pseudocapsule formation are relevant factors of malignant behavior of small RCC and could be considered in prognosis evaluation.

    Clinicopathologic features and prognostic analyses of locally recurrent renal cell carcinoma patients after initial surgery
    Qi TANG,Rong-cheng LIN,Lin YAO,Zheng ZHANG,Han HAO,Cui-jian ZHANG,Lin CAI,Xue-song LI,Zhi-song HE,Li-qun ZHOU
    2019, (4):  628-631.  doi: 10.19723/j.issn.1671-167X.2019.04.005    
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    Objective: To evaluate the clinicopathologic features and potential prognostic predictors of locally recurrent renal cell carcinoma patients after initial surgery.Methods: Authors retrospectively analyzed data extracted from 81 patients who were treated for postoperative locally recurrence of renal cell carcinoma from January 2006 to June 2016 in the Department of Urology, Peking University First Hospital. Postoperative locally recurrence of renal cell carcinoma was defined as disease recurring in the remnant kidney, renal fossa, adjacent abdomen, ipsilateral adrenal and retroperitoneal lymph nodes.Results: In the study, 81 patients were finally included, of whom 43 were initially treated in our hospital and 38 were initially treat in other centers. Partial nephrectomy (PN) was performed for 38 cases (26 in our hospital and 12 in other hospitals) as initial treatment and radical nephrectomy (RN) was conducted for the remnant 43 cases (17 in our hospital and 26 in other hospitals). Overall median recurrence time was 26 months (range: 3-164 months), in which 26 months (range: 3-55 months) for PN cases and 30 months (range: 4-164 months) for RN cases (P=0.009). Sixty-nine patients had single site recurrence, including remnant kidney (n=29), renal fossa (n=20), abdomen (n=4), ipsilateral lymph nodes (n=5), ipsilateral adrenal (n=11), while 12 patients had multiple sites recurrence. Seventy-eight patients were managed by complete surgical resection, while three patients were managed by radiofrequency ablation. Postoperative pathological diagnoses included clear cell carcinoma (n=72), papi-llary renal cell carcinoma (n=8, 7 cases with type 1, 1 case with type 2) and Xp11 translocation/TFE3 gene fusion renal cell carcinoma (n=1). Complete pathologic information of the initial surgery could be extracted from 43 patients who were initially treated in our hospital. Seventeen patients with initial radical nephrectomy were staged as T1a (n=4), T1b (n=2), T2a (n=1), T3a (n=8), and T3b (n=2). Twenty-six patients with initial partial nephrectomy were staged as T1a (n=18), T1b (n=7), and T3a (n=1). For PN cohort, the patients with T1a stage disease had longer median recurrence time than those with beyond T1a stage disease, and the difference was significant (29 months vs. 18 months, P=0.041). At the end of the follow-up, 58 patients were alive, 4 died and 19 lost the follow-up. Overall, 3-year and 5-year disease free survival rates were 81.9%, and 53.6%, respectively.Conclusion: The present research reported a large-scale single central experience of locally recurrent renal cell carcinoma. The recurrence time of the PN group is shorter than that of the RN group. For patients after PN surgery, median recurrence time is longer for patients with T1a stage tumor when compared with those with stage beyond T1a. Patients can obtain relative long-term survival after complete secondary surgery resection.

    Analysis of intratesticular condition in micro-dissection testicular sperm extraction era
    Lian-ming ZHAO,Hui JIANG,Kai HONG,Hao-cheng LIN,Wen-hao TANG,De-feng LIU,Jia-ming MAO,Zhe ZHANG,Sheng-li LIN,Lu-lin MA
    2019, (4):  632-635.  doi: 10.19723/j.issn.1671-167X.2019.04.006    
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    Objective: To summarizes the intratesticular condition of azoospermia patients, to understand azoospermia more intuitively, and improve the ability of clinical doctors to predict the success rate of microsperm extraction in azoospermia patients.Methods: Azoospermia patients (excluding Klinefelter’s syndrome) who underwent a micro-TESE during January 2014 and January 2018 in a single center were enrolled. The types of seminiferous tubules were summarized, and the clinical characteristics of different types of seminiferous tubules compared with the success rates of sperm extraction. In this study, 472 cases of non-obstructive azoospermia (excluding Klinefelter’s syndrome) were analyzed by SPSS 21.0 software package. Relevant data were expressed by median(minimum,maximum).t-test was used to compare the difference of success rate of sperm extraction between each group and the group with the lowest rate (a type).Results: The 472 patients with non-obstructive azoospermia underwent micro-TESE. The mean age of the patients was 31(23,46) years, the mean testicular size was 10(1,20) mL, the mean FSH was 15.4(1.21,68.4) IU/L, the mean T was 8.34(0.69,30.2) nmol/L, and totally 202 patients achieved success in micro-TESE (42.7%, 202/472). According to the seminiferous tubules seen during the operation, they were divided into the following six types: Class a, seminiferous tubules developed well and uniformly; Class b, seminiferous tubules developed well, occasionally slightly thick; Class c, seminiferous tubules were generally thin; Class d, seminiferous tubules basically atrophied, occasionally well-developed seminiferous tubules; Class e, all seminiferous tubules atrophied; Class f, seminiferous tubules were infiltrated by yellow substances. The success rate of micro-TESE varied greatly among different types of the patients. A total of 78 patients with type a were 29(24,40) years old, FSH 11.1(1.21,15.8) IU/L, T10.2(3.29,26.5) nmol/L), and testicular size 12(12,20) mL. The successful rate of sperm extraction was 6.41%; 82 patients with type b were 31(23,42)years old, FSH 13.8(3.23,19.6) IU/L, T9.44(3.58,30.2) nmol/L), and testicular size 12(8,15) mL. The successful rate of sperm extraction was 74.39%; There were 162 patients in group c, aged 31(25,40), FSH 19.6(9.28,26.6) IU / L, T 8.75(5.66,18.6) nmol/L, and testicular size 8(5,12) mL. The successful rate of sperm extraction was 45.06%. There were 36 patients in group d, aged 25(23,38) years and FSH 28.5(19.3,45.6) IU/L, T6.52(2.12,9.83) nmol/L, and testicular size 5(3,8) mL, and the success rate of sperm extraction was 94.44%. 26 patients with type e were 28(23,46) years old, FSH31.3(18.5,68.4) IU/L, T6.72(0.69,18.2) nmol/L, and testicular size 5(1,8) mL. The success rate of sperm extraction was 45.38%. 88 patients with type f were 29(24,38) years old, FSH18.5(5.23,31.6) IU / L, T8.32(3.58,16.5) nmol/L, and testicular size 12(6,20) mL. The success rate of sperm extraction was 28.41%.Conclusion: The success rate of micro-TESE in different types of seminiferous tubules in testis can be helpful to the judgement of the surgeon during the operation.

    Complications and management for penile augmentation with acellular dermal matrix
    Ting-min XU,Xiao-wei ZHANG,Guo-xi ZHANG,Wen-jun BAI,Qing LI,Tao XU
    2019, (4):  636-640.  doi: 10.19723/j.issn.1671-167X.2019.04.007    
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    Objective: To investigate and analyze the complications of penile augmentation with acellular dermal matrix (ADM) and following management.Methods: This was a retrospective review of all patients who received penile augmentation with ADM between June 2016 and January 2019. The patients were evaluated with outpatient physical examination. Related complications and following management were summarized and analyzed.Results: Between June 2016 and January 2019, ADM was used as filling material on 78 patients (mean age: 31.14 years, range: 21-66 years), who were successfully received penile augmentation surgery. In the follow-up three months, the penile circumference was increased by 1.1 cm (0.5-2.1 cm) on average. The mean follow-up time was 12.20 months. In this study, there were 47 (60.26%, 47/78) patients with erectile discomfort, 91.49% (43/47) of whom manifested as erectile traction. There were 12 (15.38%, 12/78) patients with delayed healing, improved by daily regular dressing change. There were 10 (12.82%, 10/78) patients with unobvious augmentation effect. There were 9 (11.54%, 9/78) patients with stamp-like changes of ADM. There were 8 (10.26%, 8/78) patients with wound hematoma and 7 (8.97%, 7/78) patients with foreskin edema, relieved by compression with wrap. There were 4 (5.13%, 4/78) patients with wound infection and 3 (3.85%, 3/78) patients with skin necrosis of the dorsal side, which could be treated with ADM removal and repair surgery with bipedicle scrotal flap. And there were 2 (2.56%, 2/78) patients suffering psychological influence. Finally, most patients with various complications recovered successfully, however 7 patients (8.97%, 7/78) underwent ADM removal surgery.Conclusion: Using ADM as filling material could achieve positive effect in penile augmentation but the complications are common and cannot be neglected. Standardized surgical methods, rigorous postoperative care, and adequate notification with patients can effectively reduce the complications of penile augmentation with ADM. To treat properly and timely for complications can obtain satisfactory results.

    Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap
    Jian-wei WANG,Li-bo MAN,Guang-lin HUANG,Feng HE,Hai WANG,Hai-dong WANG,Xiao XU,Wei LI,Jian-po ZHAI,Zhen-hua LIU
    2019, (4):  641-645.  doi: 10.19723/j.issn.1671-167X.2019.04.008    
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    Objective: To evaluate the clinical effect of single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap.Methods: We retrospectively reviewed the clinical database of 22 male patients with penile urethral stricture who received single-stage repair using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap from November 2015 to October 2018. All the cases had no complications, such as skin fistula. The causes of stricture included iatrogenic (14/22, 63.6%), inflammation (2/22, 9.1%) and idiopathic (6/22, 27.3%). A ventral urethrotomy was made in the segment of stricture and extended proximally and distally until the normal calibre urethra was encountered. The oral mucosa graft was secured to the corpus spongiosum in dorsal onlay fashion or underlying corpora cavernosum after resection of the severe scarred urethra. Then the prepared Orandi fasciocutaneous penile skin flap was secured to edges of corpus spon-giosum or oral mucosa graft. A 16 F or 14 F Foley catheter was left in situ for a minimum of 3 weeks, at which time a urethrogram was performed to look for extravasation, and the urethroscopy was performed if necessary. Success was defined as an open urethra with Qmax ≥15 mL/s and no need for further surgical intervention.Results: all the 22 patients with a mean age of 52.6 (18-73) years underwent the combined tissue-transfer technique. The mean length of the penile urethral stricture was 5.3 (2.5-10.0) cm and the mean preoperative Qmax was 6.7 mL/s. the mean length of oral mucosa grafts and fasciocutaneous skin flaps were 5.5 (3.2-10.5) cm and 6.0 (3.5-11.0) cm, respectively. The mean operation time was 225 (150-420) minutes and the mean evaluated blood loss was 53 (20.0-110.0) mL. The grafts included buccal mucosa (19/22, 86.4%) and lingual mucosa (3/22, 13.6%). The mean postoperative Q max was 21.2 (15-32) mL/s. A case of skin fistula and 2 cases of recurrent stricture were found, so the technique success rate was 81.8% (18/22) at a mean follow-up of 20.5 (5-51) months. The perioperative complications included 2 cases of infection and skin necrosis, which healed well after conservative treatment.Conclusion: Single-stage repair of penile urethral stricture using combined dorsal onlay oral mucosa grafting with ventral onlay penile skin flap appears to be an excellent option to repair penile urethral stricture with unsalvageable urethral plate and the penile skin is available. The present clinical series showed a successful rate of 81.8% (18/22).

    Comparison of efficacy and safety between two different methods of nephroureterectomy in two centers
    Jin-feng WU,Rong-cheng LIN,You-cheng LIN,Wang-hai CAI,Qing-guo ZHU,Dong FANG,Geng-yan XIONG,Lei ZHANG,Li-qun ZHOU,Lie-fu YE,Xue-song LI
    2019, (4):  646-652.  doi: 10.19723/j.issn.1671-167X.2019.04.009    
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    Objective: To compare the efficacy and safety of complete transperitoneal laparoscopic nephroureterectomy (CTNU) and traditional retroperitoneoscopic nehroureterectomy (TRNU) for the management of upper urinary tract urothelial carcinoma(UTUC).Methods: We retrospectively collected the clinical data of UTUC patients who underwent CTNU or TRNU surgery from January 2011 to December 2018 in Peking University First Hospital and Fujian Provincial Hospital, and compared the clinical characteristics, perioperative parameters, and follow-up results between the CTNU and TRNU surgeries.Results: Finally, a total of 266 cases were included, with 94 cases in the CTNU group and 172 cases in the TRNU group. The proportion of left side lesions was bigger in TRNU group when compared with CTNU group (P<0.05). No significant differences were observed in clinical characteristics, such as age, gender, body mass index(BMI), American society of anesthesiologists score(ASA score) and tumor laterality. All surgery procedures were completed. The vascular resparing was performed by reason that left arteria renalis was injured accidently during surgical operation in one case of TRNU group. No serious complications were observed in both CTNU and TRNU groups. In CTNU group, operating time was (202.9±76.7) min, estimated blood loss was (68.4±73.3) mL, drainage duration was (3.9±1.5) d, drainage volume was (181.7±251.5) mL, and postoperative hospital stay was (7.8±4.1) d. In TRNU group, operating time was (203.5±68.7) min, estimated blood loss was (130.2±252.1) mL, drainage duration was (4.3±1.6) d, drainage volume was (179.1±167.5) mL, and postoperative hospital stay was (8.2±3.7) d. The estimated blood loss in CTNU group was significantly less than that in TRNU group (P =0.005).The median follow-up time was 39 months (range: 1-88 months). The 5-year overall survival rate (OS), cancer specific survival rate (CSS), intra-vesical recurrence free survival rate (IvRFS), disease free survival rate (DFS) of CTNU group was 75.6%, 86.9%, 73.8%, 57.5%, respectively. The OS, CSS, IvRFS and DFS of TRNU group was 66.3%, 83.5%, 75.9%, 58.6%, respectively.No significant differences were observed in the OS, CSS, IvRFS and DFS between the CTNU and TRNU groups.Conclusion: CTNU technique is a safe and effective surgical option, and further prospective randomized controlled trial is needed for further evaluation.

    Application of machine learning models in predicting early stone-free rate after flexible ureteroscopic lithotripsy for renal stones
    Xue-hua ZHU,Ming-yu YANG,Hai-zhui XIA,Wei HE,Zhi-ying ZHANG,Yu-qing LIU,Chun-lei XIAO,Lu-lin MA,Jian LU
    2019, (4):  653-659.  doi: 10.19723/j.issn.1671-167X.2019.04.010    
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    Objective: To establish predictive models based on random forest and XGBoost machine learning algorithm and to investigate their value in predicting early stone-free rate (SFR) after flexible ureteroscopic lithotripsy (fURL) in patients with renal stones.Methods: The clinical data of 201 patients with renal stones who underwent fURL were retrospectively investigated. According to the stone-free standard, the patients were divided into stone-free group (SF group) and stone-residual group (SR group). We compared a number of factors including patient age, body mass index (BMI), stone number, stone volume, stone density and hydronephrosis between the two groups. For low calyceal calculi, renal anatomic parameters including infundibular angle (IPA), infundibular width (IW), infundibular length (IL) and pelvic calyceal height (PCH), would be measured. We brought above potential predictive factors into random forest and XGBoost machine learning algorithm respectively to develop two predictive models. The receiver operating characteristic curve (ROC curve) was established in order to test the predictive ability of the model. Clinical data of 71 patients were collected prospectively to validate the predictive models externally.Results: In this study, 201 fURL operations were successfully completed. The one-phase early SFR was 61.2%. We built two predictive models based on random forest and XGBoost machine learning algorithm. The predictive variables’ importance scores were obtained. The area under the ROC curve (AUROC) of the two predictive models for early stone clearance status prediction was 0.77. In the study, 71 test samples were used for external validation. The results showed that the total predictive accuracy, predictive specificity and predictive sensitivity of the random forest and XGBoost models were 75.7%, 82.6%, 60.0%, and 81.4%, 87.0%, 68.0%, respectively. The first four predictive variables in importance were stone volume, mean stone density, maximal stone density and BMI in both random forest and XGBoost predictive models.Conclusion: The predictive models based on random forest and XGBoost machine learning algorithm can predict postoperative early stone status after fURL for renal stones accurately, which will facilitate preoperative evaluation and clinical decision-making. Stone volume, mean stone density, maximal stone density and BMI may be the important predictive factors affecting early SFR after fURL for renal stones.

    Treatment of crossing vessels in laparoscopic pyeloplasty
    Hai-yue ZHAO,Xiong-jun YE,Wei-nan CHEN,Li-zhe AN,Jun LIU,Liu-lin XIONG,Xiao-bo HUANG
    2019, (4):  660-664.  doi: 10.19723/j.issn.1671-167X.2019.04.011    
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    Objective: To investigate the management of crossing vessels compression in laparoscopic pyeloplasty.Methods: From January 2016 to June 2018, a total of 21 patients who were admitted to Peking University People’s Hospital with ureteropelvic junction obstruction (UPJO) associated with crossing vascular compression were reviewed. There were 15 males and 6 females who formed this group, with a mean age of (33.9±15.0) years. There were 4 cases of mild hydronephrosis, 12 cases of moderate hydronephrosis and 5 cases of severe hydronephrosis before operation. All the patients underwent laparoscopic pyeloplasty in our hospital, including 13 on the left and 8 on the right. Laparoscopic pyeloplasty (Anderson-Hynes) were performed in all the patients. Hem-o-lok suspension (14 cases in the suspension group) or translocation of the crossing vessels (7 cases in the translocation group) were used for the intraoperative management of the crossing vessels. Double J tubes were removed 8 weeks postoperatively. The patient demographic data were collected (including operation time, treatment time of crossing vessels, intraoperative blood loss, time of drainage tube removal after operation, and average length of hospital stay), postoperative outcomes were evaluated and the patients were followed up regularly.Results: In all the patients, the crossing vessels were successfully reserved, and none of them were ligated intra-operatively. Mean operative times were (202.2±57.0) min. The duration of intraoperative treatment of crossing vessels was (10.5±3.2) min, (6.1±2.0) min in the suspension group, and (13.7±5.2) min in the translocation group, respectively. Intraoperative blood loss was (47.8±25.6) mL, postope-rative drainage time was (4.8±2.6) d, and length of hospital stay was (11.5±3.3) d. Postoperative slight urinary leakage occurred in 1 case. Preoperative pyelectasis of the affected side of all the patients was (3.4±1.7) cm, compared with postoperative pyelectasis of (1.9±1.3) cm. The difference was statistically significant (P<0.05). Postoperative follow-up of all the patients was carried out until December 2018. There was no significant difference in kidney size in all the patients before or after the operations, and hydronephrosis was alleviated compared with that before surgery.Conclusion: For UPJO patients with crossing vascular compression, according to the location of the crossing vessels, Hem-o-lok suspension or vessel transposition can be adopted to relieve the crossing vascular compression and improve the success rate of the surgery.

    Impact of diagnostic ureteroscopy and biopsy on radical nephroureterectomy of upper tract urothelial carcinoma
    Run-zhuo MA,Hai-zhui XIA,Min LU,Zhi-ying ZHANG,Qi-ming ZHANG,Jian LU,Guo-liang WANG,Lu-lin MA
    2019, (4):  665-672.  doi: 10.19723/j.issn.1671-167X.2019.04.012    
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    Objective: To investigate the impact of preoperative diagnostic ureteroscopy and biopsy (UB) on radical nephroureterectomy (RNU) and the prognosis of upper tract urothelial carcinoma (UTUC).Methods: The clinical data of UTUC patients receiving RNU between Jan. 2007 and Dec. 2016 were retrospectively collected. The median follow up time was 40 months. The operation time and blood loss of RNU were compared between UB group and non-UB group. Subgroup analyses were conducted according to the time interval between UB and RNU, and surgery methods of lower ureter. The linear regression model was used to adjust for other common factors that impacted operation time.Results: A total of 163 UTUC patients were included in the final analysis. For the lower ureter, open ureterectomies were performed in 91 patients (55.9%), while retroperitoneal laparoscopic ureterectomies were performed in 72 patients (44.1%). A total of 110 (67.5%) patients received preoperative UB. Compared with non-UB group, the average operation time of UB group was significantly longer [(252.5±79.8) min vs. (221.3±79.8) min, P=0.019], but no difference of blood loss was found (median, 50 mL vs. 50 mL, P=0.143). In subgroup analysis, the average operation time of RNU was significantly prolonged when RNU was performed after 1 week of UB (P=0.023). Meanwhile, the median blood loss of RNU increased significantly when it was done after 2 weeks of UB compared with non-UB group (100 mL vs. 50 mL, P=0.012). UB was also significantly prolonged the operation time of RNU in retroperitoneal laparoscopic ureterectomy group (P=0.012). In multivariable analysis, UB (P=0.049), ≥pT3 (P=0.039), pN+ (P=0.018) and ureterectomy method (P=0.005) were independent risk factors of prolonged operation time. The 3-year cancer specific survival (CSS) rate was 87.2% in our cohort. UB had no significant impact on cancer specific survival (P=0.435).Conclusion: UB was an independent risk factor of prolonged RNU time, but did not significantly influence cancer specific survival of upper tract urothelial carcinoma patients.

    Evaluating inferior vena cava wall invasion in renal cell carcinoma tumor thrombus with MRI
    Jing-yun WU,Yue MI,Shui LIU,Lin YAO,Qi TANG,Zhi-song HE,Xiao-ying WANG
    2019, (4):  673-677.  doi: 10.19723/j.issn.1671-167X.2019.04.013    
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    Objective: To evaluate the diagnostic performance of MRI for the assessment of inferior vena cava (IVC) wall invasion by IVC thrombus in patients with renal cell carcinoma (RCC).Methods: We retrospectively collected patients who underwent radical nephrectomy and thrombectomy for RCC between 2010 and 2018 at Peking University First Hospital. All the patients underwent imaging on a 1.5 Tesla or 3.0 Tesla MRI scanner. Fifty-six patients met the inclusion criteria. Preoperative imaging was reviewed by two radiologists blinded to details of the patient’s surgical procedure and histopathology. Two radiologists measured the maximum anterior-posterior diameter and coronal diameters of the IVC and renal vein, and the craniocaudal extent of tumor thrombus, and evaluated the MRI features of IVC thrombus, including occlusion of the IVC lumen,the margin of the tumor thrombus (smooth vs. irregular), contact of the IVC thrombus and IVC wall, and altered signal of the IVC wall. Univariable and multivariable associations of clinical and radiographic features with IVC wall invasion were evaluated by Logistic regression.Results: Of the 56 patients [male: 43, female: 13, mean age: (55.64±0.43) years], 17 (30.36%) were detected with IVC wall invasion, and most were clear cell carcinoma. Tumor thrombus with IVC wall invasion showed an increase in length of IVC thrombus [(7.91±3.59) cm vs. (5.94±3.57) cm, P=0.049], and more features of complete occlusion of the IVC lumen (P=0.002),irregular margin of the IVC thrombs (P=0.005), contact of the IVC thrombus and IVC wall (P=0.001), and altered signal of the low-intensity vessel wall (P<0.001), with a sensitivity of 94.12% and a specificity of 79.49%.Conclusion: The present study indicates that MRI could be a means of evaluating RCC with IVC wall invasion, and the combination of tumor thrombus length and subjective impression of IVC wall invasion achieved a high sensitivity and specificity for diagnosis.

    Comparison of various imaging in the diagnosis of renal cell carcinoma with inferior vena cava tumor thrombus combined with bland thrombus
    Li-wei LI,Zhuo LIU,Guo-liang WANG,Hua ZHANG,Wen CHEN,Jing MA,Li ZHANG,Wei HE,Lu-lin MA,Shu-min WANG
    2019, (4):  678-683.  doi: 10.19723/j.issn.1671-167X.2019.04.014    
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    Objective: To analyse the clinical and imaging data of patients with renal cell carcinoma (RCC) with inferior vena cava tumor thrombus (IVCTT), and to assess the diagnostic efficacy of ultrasound, enhanced computed tomography (CT) and enhanced magnetic resonance imaging (MRI) in the diagnosis of RCC with IVCTT combined with bland thrombus was assessed.Methods: We retrospectively analyzed the clinical and imaging data of 56 RCC patients with IVCTT who underwent radical nephrectomy and IVC thrombectomy between January 2014 and July 2018 in Department of Urology, Peking University Third Hospital. All the patients underwent US, enhanced CT and enhanced MRI preoperatively, and all the cases were confirmed with RCC with IVCTT by histological evaluation.Results: The criteria of RCC with IVCTT combined with bland thrombus was confirmed by intraoperative observation and postoperative pathology. The 56 patients were divided into bland thrombus group (n=18) and non bland thrombus group (n=38). Compared the two groups, it was found that the length of IVCTT was longer [(10.50 ± 5.55) cm vs.(6.66 ± 3.73) cm, P=0.014]; the ratio of diameter of IVCTT to maximum coronal diameter of IVC was closer to 1 [1.0 (0.7, 1.0) vs. 0.9 (0.2, 1.0), P=0.004]; the proportion of lower limb edema was higher [66.7(12/8)% vs.5.3%(2/36), P=0.005];the proportion of segmental resection or interrupt of IVC was higher [66.7%(12/18) vs.15.8%(6/38), P<0.001], with statistical significance. Compared with the three imaging methods of US, enhanced CT and MRI, the highest sensitivity was MRI (77.8%), the highest specificity was enhanced MRI and enhanced CT (97.4%), the highest accuracy was enhanced CT and enhanced MRI (83.9%), the highest positive predictive value was enhanced CT (90.9%) and the highest negative predictive value was enhanced MRI (89.2%).Conclusion: For the patients that RCC with IVCTT combined with bland thrombus, the length of IVCTT is longer, and the ratio of the diameter of IVCTT to the maximum corona diameter of IVC is closer to 1, and more likely to cause lower limb edema. Preoperative comprehensive evaluation of multiple images is needed to improve the accuracy of diagnosis.

    Diagnosis and surgical treatment of massive adrenal area tumor with tumor thrombus
    Lei LIU,Guo-liang WANG,Lu-lin MA,Min LU,Cheng LIU,Xiao-fei HOU
    2019, (4):  684-688.  doi: 10.19723/j.issn.1671-167X.2019.04.015    
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    Objective: To summarize the experience of diagnosis and operation related to massive adrenal area tumor with venous tumor thrombus in clinic.Methods: From October 2017 to March 2019, a total of 8 cases of massive adrenal area tumor (>7 cm) with venous tumor thrombus were admitted at Peking University Third Hospital including 5 males and 3 females with mean age 50.6 years (31-62 years). There were 6 cases on the right side and 2 cases on the left side. The first symptoms included abdominal discomfort, hypertension, Cushing syndrome and abnormal menstruation; special past history included cirrhosis and lung cancer. Computed tomography (CT) and routine endocrine hormone tests were examined. Preoperative imaging confirmed 5 cases masses with tumor thrombus in inferior vena cava (IVC) and 1 case with tumor thrombus in left renal vein. Two cases presented with tumor thrombus in central adrenal vein were found intraoperatively. Open adrenalectomy and thrombectomy were performed in 4 cases of right side complicated with high tumor thrombus of inferior vena cava. Laparoscopic adrenalectomy and thrombectomy were performed in 3 cases, including 2 cases on the right and 1 case on the left. The case with tumor thrombus in left renal vein gave up operation. The patients were followed up with outpatient and telephone.Results: The mean size of the tumor was 8.9 cm (7-11 cm), the mean operative time was 319 min (120-510 min), while the estimated blood loss was 629 mL (50-1 200 mL). Intraoperative blood transfusion was required in 2 cases and 1 case encountered wound infection. The pathological types included pheochromocytoma, adrenocortical carcinoma, adrenal metastases of haptic carcinoma, and leiomyosarcoma. The case with left lung carcinoma who underwent left pneumonectomy one month before was highly suspected adrenal metastases of lung carcinoma. Tumor thrombus of pheochromocytoma was combined with blood thrombus. Capsule of adrenocortical carcinoma was fragile in adrenocortical carcinoma. Abundant blood supply existed in adrenal metastases. The leiomyosarcoma had unabundant blood supply and invaded IVC to form tumors thrombus. The mean follow-up time was 8.4 months (1-15 months). One case with adrenocortical carcinoma died after 1 year in the follow-up.Conclusion: We present the rare cases of different pathological types of massive adrenal tumors with tumor thrombus extending into the IVC extension or other vein. Preoperative diagnosis needs comprehensive evaluation and perfect preoperative preparation. Surgery is difficult and varied. Open approach as well as retroperitoneal laparoscopic approach is feasible.

    Retrospective study of diagnosis and treatment of renal oncocytoma
    Min QIU,Yong-wang ZHANG,Yue-yang FEI,Cheng LIU,Shao-hui DENG,Wei HE,Min LU,Jian LU,Xiao-fei HOU,Lu-lin MA
    2019, (4):  689-693.  doi: 10.19723/j.issn.1671-167X.2019.04.016    
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    Objective: To summarize the experience of diagnosis and surgical treatment of renal oncocytoma, and to evaluate the surgical results based on follow-up results, in order to find the best strategy.Methods: In the study, 21 cases with renal oncocytoma from December 2003 to April 2016 in Peking University Third Hospital were retrospectively analyzed, including 4 males, and 17 females, with 10 cases on the right side and 11 cases on the left side. Their age was between 15 to 80 years (average: 58 years). Ultrasound or CT examination after admission was conducted. Ultrasound examination showed solid nodules. CT manifestations were solid masses with enhancement, and the tumor size was between 1.5 cm to 6.5 cm (average: 3.3 cm). Of the 21 cases, 9 were located in the middle of kidney, 7 were located in the upper pole, and 5 were located in the lower pole. After preoperative examination, according to the size and location of the tumor, laparoscopic partial nephrectomy or laparoscopic nephrectomy was performed, respectively.Results: All the operations were successful, in which 17 cases underwent laparoscopic partial nephrectomy (including 3 cases which were converted to open surgery), and 4 cases underwent laparoscopic radical nephrectomy. The operation time ranged from 75 to 274 min (mean: 144 min), and the blood loss ranged from 10 to 1 000 mL (mean: 115 mL). The postoperative hospital stay time ranged from 6 to 13 d (average: 8.2 d). The pathological results were all renal oncocytoma. In the study, 17 cases were followed up while 4 cases were lost to follow-up. The follow-up time ranged from 12 to 175 months (mean: 44 months). One case died in 20 months after operation with unknown reason, and there were no recurrence or metastasis in the other 16 cases.Conclusion: Renal oncocytoma is a benign tumor with good prognosis. Enhanced CT is an effective diagnostic method in assistant examination, but it is difficult to differentiate clear cell carcinoma only from the naked eye. It is worthwhile to measure CT value at different stages of the tumor by picture archiving and communication systems (PACS), and to compare with CT value of adjacent kidney tissue may improve the diagnostic efficiency of CT. Laparoscopic surgery is an effective treatment for renal oncocytoma. We recommend laparoscopic partial nephrectomy for the patients with renal oncocytoma as the best choice if conditions permit.

    Long-term follow-up of the efficacy of tension-free vaginal tape and trans-obturator tape for different types of stress urinary incontinence
    Xian-hui LIU,Wei-yu ZHANG,Hao HU,Qi WANG,Tao WANG,Yong-xin HE,Ke-xin XU
    2019, (4):  694-697.  doi: 10.19723/j.issn.1671-167X.2019.04.017    
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    Objective: To evaluate the long-term efficacy of tension-free vaginal tape(TVT)and trans-obturator tape(TOT)for different types of female stress urinary incontinence(FSUI).Methods: The cli-nical data of all female patients with stress urinary incontinence (SUI) who underwent mid-urethral slings (MUS) in Peking University People’s Hospital from January 2008 to June 2016 were retrospectively analyzed,and all the patients were followed up. Based on the level of abdominal leak point pressure (ALPP), the patients with ALPP lower than or equal to 60 cmH2O (1 cmH2O=0.74 mmHg) were regarded as intrinsic sphincter deficiency (ISD) type, and the patients with ALPP higher than 60 cmH2O were regarded as non-ISD type. According to the degree of remission of leakage of urine by using the International Consultation on Incontinence Questionnaire Short Form (ICI-Q-SF), the surgical outcomes were divided into three categories: cured, improved or failed. The efficacy of TVT and TOT for different types of FSUI was evaluated by comparing the cure rate of TVT with the cure rate of TOT in ISD type and non-ISD type separately.Results: A total of 170 patients were included in this study. The patients were among 30-78 years, and the follow-up period were among 12-110 months. In the study, 117 patients belonged to non-ISD type. Of whom 30 underwent TVT with a cure rate of 86.7% (26/30), and the other 87 underwent TOT with a cure rate of 69.0% (60/87). The cure rate of TVT was higher than that of TOT in non-ISD type, however, Chi-square test showed that there was no significant difference (χ 2=3.589, P>0.05). In addition, 53 patients belonged to ISD type, of whom 16 underwent TVT with a cure rate of 87.5% (14/16), and the other 37 underwent TOT with a cure rate of 51.4% (19/37). The cure rate of TVT was higher than that of TOT in ISD type, and Chi-square test showed that the difference was statistically significant (χ 2=6.212, P<0.05).Conclusion: For the treatment of FSUI, MUS can achieve satisfactory long-term efficacy. For non-ISD type, the cure rates of TVT and TOT are similar, while for ISD type, the cure rate of TVT is higher than that of TOT.

    Propensity-matched comparison of laparoscopic and open radical cystectomy for female patients with bladder cancer
    Hai-wen HUANG,Bing YAN,Mei-xia SHANG,Li-bo LIU,Han HAO,Zhi-jun XI
    2019, (4):  698-705.  doi: 10.19723/j.issn.1671-167X.2019.04.018    
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    Objective: To compare the perioperative and oncologic outcomes of female patients recei-ving laparoscopic radical cystectomy (LRC) and open radical cystectomy (ORC).Methods: Retrospective review of 91 consecutive female patients with urothelial carcinoma of bladder undergoing radical cystectomy at a single academic institution from 2006 to 2017. Those female patients received open radical cystectomy were matched to the patients who underwent laparoscopic radical cystectomy by using propensity score matching in 1 :1 ratio. The matching factors included age, body mass index (BMI), American Society of Anesthesiologists (ASA) score, pathologic stage and pathologic nodal stage. The periope-ration and oncology characteristics were compared, and Kaplan-Meier method was used to analyze the overall survival (OS), cancer specific survival (CSS) and progression-free survival (PFS) estimates. Finally, we did a sensitive analysis by using multivariable COX regression of all the patients, adjusting for the matching factors.Results: There were 65 ORC and 26 LRC patients identified in this cohort with urothelial carcinoma of bladder, the median follow-up time was 38 months (interquartile range 18-69). The age (P<0.001) and ASA scores (P=0.018) were less for LRC before being matched. There were 22 LRC and 22 ORC patients matching successfully. Before being matched, the estimate blood loss (P=0.005), transfusion rate (P<0.001) and total complications rate (P=0.015) were less for LRC, and the lymph nodes yield was greater for LRC, but there were no differences in OS (P=0.698), CSS (P=0.942) and PFS (P=0.837) between the two groups. After being matched, the estimate blood loss (P=0.009), transfusion rate (P=0.001) and total complications rate (P=0.040) were less for LRC, but there was no difference in the lymph nodes yield. Besides, there were no statistic differences in OS (P=0.432), CSS (P=0.429) and PFS (P=0.284) between the two groups. In addition, in multivariable COX regression analysis, surgical approaches (LRC/ORC) were not found to be a predictor of OS (HR 1.134, 95%CI 0.335-3.835, P=0.839), CSS (HR 1.051, 95%CI 0.234-4.719, P=0.949) and PFS (HR 0.538, 95%CI 0.138-2.095, P=0.371) of the female patients with urothelial carcinoma of bladder.Conclusion: It is advantageous for laparoscopic radical cystectomy in terms of estimating blood loss, transfusion rate and complication rate. But there was no evidence that laparoscopic radical cystectomy for female patients with bladder cancer had a better oncologic prognosis than open radical cystectomy from this study.

    A survey of risk factors and quality of life in female medical staff with urinary incontinence
    Xin-yan CHE,Shi-liang WU,Yu-ke CHEN,Yan-bo HUANG,Yang YANG
    2019, (4):  706-710.  doi: 10.19723/j.issn.1671-167X.2019.04.019    
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    Objective: To explore risk factors of urinary incontinence (UI) and influences of UI on quality of life in female medical staff from Beijing.Methods: One hundred and forty-six female medical personnel were included in the present study through the convenient sampling method in Peking University First Hospital. The questionnaires contained the following information: demographic information, daily urination condition, the severity of UI [international consultation on incontinence questionnaire short form (ICI-Q-SF)], and the influences of UI on quality of life (QOL). We excluded the subjects who were in pregnancy or had urinary infection, neurogenic bladder, or urethral stricture. We used SPSS 21.0 software (IBM Corp, Armonk, NY) for statistical analysis. The Kolmogorov-Smirnov test determined the normality of the continuous variables. Means and standard deviation presented continuous variables in normality. Median and range presented continuous variables without normality. Frequency and percentile were used to present categorical or ranked variables.Results: There were 63 out of 146 (43.2%) female medical staff suffering from UI. The mean age and body mass index of the whole study cohort were (39.4±9.9) years and (22.3±3.4) kg/m 2. The median delivery times of all the subjects were 1 time (range: 0-3 times). Fifty out of 146 (34.2%) subjects had transvaginal delivery history. Chronic constipation was diagnosed in 32 subjects (21.9%). No significant difference in daytime micturition and nocturia times were found between the UI and non-UI subjects. According to the multivariate analysis, chronic constipation (OR=4.95, 95%CI=1.81-13.53, P=0.002) and transvaginal delivery history (OR=3.50, 95%CI=1.49-8.21, P=0.004) were independent risk factors for UI. The non-UI subjects had superior quality of life than the UI subjects in terms of incontinence quality of life (I-QOL) total scores and all sub-scores of avoidance and limiting behaviors, psychosocial impacts, and social embarrassment (P<0.001). In addition, avoidance and limiting behaviors (r=-0.449, P<0.001), psychosocial impacts (r=-0.538, P<0.001), and social embarrassment (r=-0.454, P<0.001) of the 63 UI subjects were equally influenced by the incontinence symptom.Conclusion: UI is not uncommon in female medical staff. The quality of life of medical faculty is influenced by UI in terms of avoi-dance and limiting behaviors, psychosocial impacts, and social embarrassment. Chronic constipation and transvaginal delivery history were independent risk factors for UI.

    Breastfeeding promotion strategies study on preterm infants in the neonatal intensive care unit
    Xiu-lan LI,Yan WU,Xiao-yun ZHONG,Min WANG,Li HUANG
    2019, (4):  711-715.  doi: 10.19723/j.issn.1671-167X.2019.04.020    
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    Objective: To explore the effect of breastfeeding promotion strategies on neonatal clinical outcomes of preterm infants during hospitalization in the neonatal intensive care unit (NICU).Methods: We developed breastfeeding promotion strategies, including the establishment of a multidisciplinary breastfeeding steering team, breastfeeding support of families and society, family-integrated care, kangaroo mother care, donor human milk bank, and so on. Preterm infants meeting the inclusion standard, less than 32 weeks gestational age, who were admitted to NICU from November 2015 to February 2017 were enrolled, and the eligible infants were divided into two groups (control group and intervention group) before and after policy implementation. The data of preterm infants including breastfeeding related outcomes (time to initiation of enteral feeding, time to initiation of breastfeeding, time to achieve full breastfeeding, time to achieve full enteral feeding and rate of breastfeeding), growth (extrauterine growth restriction) and complications were compared between the two groups.Results: One hundred and twenty-three preterm infants were enrolled, including 61 in the control group and 62 in the intervention group. There were no significant differences in gender, gestational age, birth weight, intrauterine growth retardation (IUGR) and admission disease status between the two groups (P>0.05). Compared with the control group, there were significantly earlier time to initiation of enteral feeding [15.37 (10.00, 22.13) h vs. 20.25 (12.88, 26.33) h, P<0.01], time to achieve full breastfeeding [91.00 (69.75, 103.00) h vs. 94.00 (80.37, 118.75) h, P=0.04], and time to achieve full enteral feeding [12 (11, 15) d vs. 14 (12, 18) d, P<0.01] in the intervention group. Otherwise, there were no significant differences in time to initiation of breastfeeding, hospital stay, extrauterine growth restriction (EUGR) occurance rate of weight, the rate of breastfeeding, motality, and the incidence of complications including feeding intolerance, neonatal necrotizing enterocolitis (NEC), bronchopulmonary dysplasia (BPD) and retinopathy of prematurity (ROP) (P>0.05).Conclusion: The breastfeeding promotion strategie was a quality improvement of ordinary breastfeeding protocol. It had significantly reduced time to initiation of enteral feeding, time to achieve full breastfeeding and time to achieve full enteral feeding for preterm infants in NICU. Further research is needed to confirm whether the strategies can improve the breastfeeding rate and reduce the occurrence of the complications, such as NEC, BPD, and ROP.

    Altered serum cytokine expression profile in systemic sclerosis and its regulatory mechanisms
    Hong-lin ZHU,Qian DU,Wei-lin CHEN,Xiao-xia ZUO,Quan-zhen LI,Si-jia LIU
    2019, (4):  716-722.  doi: 10.19723/j.issn.1671-167X.2019.04.021    
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    Objective: To analyze the expression profile of serum cytokines in patients with systemic sclerosis (SSc) and explore its possible regulatory mechanisms.Methods: Serum and DNA of peripheral blood mononuclear cells were collected from 30 SSc patients and 80 normal controls (NCs). According to the presence or absence of interstitial lung disease (ILD) in SSc, the patients were divided into SSc with ILD group and SSc without ILD group. According to the degree of skin involvement, the patients were divided into diffuse systemic scleroderma (dcSSc) group and limited systemic scleroderma (lcSSc) group. According to the presence of anti-topoisomerase-1 antibody (anti-Scl-70 antibody) in the serum of patients with SSc, they were divided into SSc Scl-70 (+) group and SSc Scl-70 (-) group. 27 cytokines in serum were detected by Luminex MAGPIX detection system and Bio-Plex Pro Human Cytokine 27-plex Assay kit: interleukin-1β (IL-1β), interleukin-1 receptor antagonist (IL-1ra), IL-2, IL-4, IL-5, IL-6, IL-7, IL-8, IL-9, IL-10, IL-12P70, IL-13, IL-15, IL-17, basic fiber growth factor (BASIC FGF), eotaxin, granulocyte colony stimulating factor (G-CSF), granulocyte-macrophage colony stimulating factor (GM-CSF), interferon-γ (IFN-γ), interferon-gamma induced protein 10(IP-10), monocyte chemotactic protein 1(MCP-1), macrophage inflammatory protein-1α(MIP-1α), macrophage inflammatory protein 1β(MIP-1β), platelet-derived growth factor BB (PDGF-BB), regulated on activation in normal T-cell expressed and secreted (RANTES), tumor necrosis factor-α (TNF-α), and vascular endothelial growth factor(VEGF). Methylation sites were detected by Illumina 450K methylation chip.Results: Compared with NCs group, the expression of 12 cytokines (BASIC FGF, eotaxin, G-CSF, GM-CSF, IFN-γ, IL-1β, IL-1ra, IL-6, IP-10, MCP-1, TNF-α and RANTES) in the SSc group significantly increased (P<0.05), IL-5 was decreased expression in the SSc group (P<0.05), there was no signi-ficant difference in the expressions of the other 14 cytokines. Compared with lcSSc group, 9 cytokines (eotaxin, IL-5, MCP-1, IL-2, RANTES, IL17A, IL-8, MIP-1β and PDGF-BB) increased in dcSSc group, but there was no significant difference. Compared with SSc without ILD group, IL-15 increased in SSC with ILD group [18.2(172.97) ng/L vs. 2.03(0.05) ng/L, P<0.05]. Compared with SSc Scl-70 (-) group, the expression of IP-10 decreased in SSc Scl-70 (+) group [1 030 (2 196.6) ng/L vs. 1 878 (2 964) ng/L, P<0.05]. The correlation analysis of serum cytokines with erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) showed that IL-6 was positively correlated with ESR (r =0.04, P= 0.017), MCP-1 (r= 0.49, P= 0.043) and MIP-1β (r= 0.41, P= 0.007) positively correlated with CRP. By analyzing the changes of methylation sites of cytokines, it was found that cg17744604 in IL-10 TSS1500 region, cg06111286 in IL-12P70 TSS200 region, cg07935264 in IL-1 β TSS200 region, cg01467417 in IL-1ra TSS1500 region, cg03989987 in IL-1ra 5'UTR region and cg21099624 in VEGF TSS200 region were all hypomethylated.Conclusion: There were different cytokines expression profiles in the serum of SSc patients, and the altered cytokines were correlected with the degree of skin damage and pulmonary fibrosis. Many cytokines were regulated by methylation.

    Relationship between podocyte injury and macrophage infiltration in renal tissues of patients with lupus nephritis
    Ying WANG,Ming-hui LI,Yan ZHANG,Xiao-yan HU,Rui-xia MA
    2019, (4):  723-727.  doi: 10.19723/j.issn.1671-167X.2019.04.022    
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    Objective: To investigate the relationship between the expression of nephrin and the infiltration of macrophages in renal tissues in patients with lupus nephritis (LN), and to provide the evidence of potential mechanism of podocyte injury in LN.Methods: In the study, 60 patients who were first diagnosed with LN by pathology were selected including 38 active LN patients with r-SLEDAI≥4, and another 10 patients of normal renal tissue were excised as a normal control group. The renal tissue and podocyte injury were observed through light and transmission electron microscope. The expression of nephrin and the infiltration of macrophages (CD68 +cells) in the renal tissue of the 60 LN patients and 10 normal cases were detected by immunohistochemical and immunofluorescence method. Different statistical analysis methods were used to analyze the correlation between the variables. Variance analysis was used for comparison among the groups, while LSD test was used for comparison between every two groups. Pearson correlation analysis was used to analyze the correlation between the variables.Results: (1)Of all the LN patients, 24 h urinary protein [(3.94±1.76) vs. (1.56±0.68), P<0.05], erythrocyte sedimentation rate (ESR) [(79.83±6.3) vs. (40.1±10.5), P<0.05] and serum creatinine [(106.58±14.9) vs. (79.1±9.89), P<0.05] were significantly increased in active group than those in inactive group, while C3 [(0.34±0.12) vs. (0.78±0.11), P<0.05], C4 [(0.07±0.04) vs. (0.17±0.10), P<0.05] and eGFR [(62.42±5.16) vs. (81.33±4.53), P<0.05] were significantly decreased in active group. (2)Compared with the normal control group, the expression of nephrin in renal tissue of the LN patients was significantly decreased, and the expression of nephrin in the active patients was significantly lower than that in inactive group (P<0.05). (3)Compared with the normal control group, the number of infiltrated macrophages in the LN patients was significantly increased, especially in the active patients (P<0.05). Macrophages were mainly found in glomeruli. (4)There was a significant negative correlation between the expression of nephrin and macrophage infiltration in renal tissues of the LN patients (r=0.761, P<0.001).Conclusion: Macrophage infiltration in renal tissues may be one of the potential mechanisms of podocyte injury in lupus nephritis.

    Biomechanical changes of sheep cervical spine after unilateral hemilaminectomy and different degrees of facetectomy
    Chao WU,Zhen-yu WANG,Guo-zhong LIN,Tao YU,Bin LIU,Yu SI,Yi-bo ZHANG,Yuan-chao LI
    2019, (4):  728-732.  doi: 10.19723/j.issn.1671-167X.2019.04.023    
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    Objective: To establish animal models and investigate the impact of unilateral hemilaminectomy(ULHL) and different degrees of facetectomy (FT) on the cervical spinal biomechanics.Methods: Twenty sheep were randomly and evenly divided into 4 groups. No operation was performed for group A, right C4-C6 ULHL was performed for group B, right C4-C6 ULHL and 50% ipsilateral C4-C5 FT was performed for group C, right C4-C6 ULHL and 100% ipsilateral C4-C5 FT was performed for group D. Animals of group A, B, C and D were sacrificed 24 weeks after operating and fresh cervical spine specimens were acquired, biomechanically tested and these data were compared to determine whether ULHL and different degrees of FT led to long-term differences in range of motion.Results: (1) Changes of the total range of motion of cervical spine 24 weeks after surgery: the total range of motion of group D (60.2°±8.6°) was significantly greater than group A (40.7°±6.4°) and group B (41.2°±13.1°) under flexion-extension station,the total range of motion of group D (81.5°±15.7°) was significantly greater than that of group A (56.7°±12.2°) and group B (57.7°±12.8°) under lateral bending station,and the total range of motion of group D (38.5°±17.5°) had no obvious increase compared with group A (26.4°±9.9°) and group B (27.1°±10.9°) under axial rotation station. The total range of motion of group C had no obvious increase compared with group A and group B under flexion-extension station (44.1°±11.7°), lateral bending station (73.6°±11.4°) and axial rotation station (31.3°±11.5°). (2) Changes of the intersegmental motion 24 weeks after surgery: the intersegmental motion of group D (20.3°±4.6°) at C4-C5 was significantly greater than that of group A (11.7°±3.4°) and group B (11.9°±2.1°) under flexion-extension station, the intersegmental motion of group D (26.8°±3.5°) at C4-C5 was significantly greater than that of group A (15.2°±3.1°) and group B (16.2°±3.2°) under lateral bending station, the intersegmental motion of group D (15.2°±3.5°) at C4-C5 was significantly greater than that of group A (6.6°±2.3°) and group B (7.1°±1.9°) under axial rotation station. The intersegmental motion of group C (21.2°±4.1°) at C4-C5 was significantly greater than that of group A and group B under lateral bending station, the intersegmental motion of group C at C4-C5 had no obvious increase compared with group A and group B under flexion-extension station (15.7°±3.7°) and axial rotation station (10.3°±3.1°).Conclusion: ULHL does not affect cervical stability, ULHL and 50% ipsilateral FT does not affect the long-term cervical stability, ULHL and 100% ipsilateral FT can lead to long-term instability under lateral bending and flexion-extension station.

    Cerebral hyper perfusion syndrome after carotid artery stenting
    Zi-chang JIA,Huan-ju BIAN,Jin-tao HAN,Hai-yan ZHAO,Jing-yuan LUAN,Chang-ming WANG,Xuan LI
    2019, (4):  733-736.  doi: 10.19723/j.issn.1671-167X.2019.04.024    
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    Objective: To explore the risk factors,clinical characteristics,precaution and treatment of hyper perfusion syndrome (HPS) after carotid artery stenting (CAS).Methods: From September 2014 to March 2018,the clinical data of 226 patients with severe carotid stenosis (70%-99%) treated with carotid artery stenting (CAS)at Department of Interventional Radiology and Vascular Surgery,Peking University Third Hospital,were analyzed retrospectively.Five of them developed HPS after CAS.The relationship between the clinical baseline data,imaging characteristics,perioperative management and HPS were assessed.Results: In this group, 5 patients of them (2.21%, 5/226) developed HPS after CAS,and 2 patients of them (0.88%, 2/226) were hyper perfusion induced intracranial hemorrhage (HICH). The 5 patients consisted of 4 men and 1 woman whose age ranged from 58 to 74 years. The symptoms of HPS occurred within 4 hours to 3 days after CAS. Among the 5 cases, the clinical manifestations were that 2 cases with headache, 1 case with delirium,1 case with hemiparesis of left limbs, and 1 case with coma(died ultimately).The main manifestations of case 1 and case 2 were headache in the frontal parietal temporal region of the operative side,accompanied by nausea and vomiting. The symptoms were relieved after blood pressure lowering treatment and mannitol dehydration. The main manifestations of case 3 were excitement and delirium. The symptoms were relieved by a small dose of sedatives,also with blood pressure lowering treatment and mannitol dehydration. The initial symptoms of case 4 were excitement and delirium, accompanied by mild headache of the operative side,and hemiplegia of the contralateral limb occurred within a short time. The main manifestation of case 5 was severe headache and went into deep coma within a short time. This patient died of massive cerebral hemorrhage ultimately.Conclusion: HPS is an uncommon but serious complication after CAS. Improving our understanding and heightening vigilance of HPS is necessary. The earlier diagnosis, the earlier treatment.

    Clinical features and prognosis of infective endocarditis patients with acute kidney injury
    Si-yu ZHANG,Xi-hui LI,Feng XIAO
    2019, (4):  737-741.  doi: 10.19723/j.issn.1671-167X.2019.04.025    
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    Objective: To investigate the clinical features and treatment of infective endocarditis (IE) patients with acute kidney injury (AKI), and to compare the adverse complications and outcome with IE patients without AKI.Methods: Clinical data of 100 IE cases in Peking University First Hospital from January 2002 to June 2018 were retrospectively reviewed. The patients were divided into AKI group (n=21) and non-AKI group (n=79) based on the AKI network (AKIN) definition. The clinical data and prognosis were compared between the two groups.Results: The incidence of AKI was 21%. The average age was (43.7±15.7) years, and the ratio of male to female was 3 :1. There was no significant diffe-rence in age and gender between the two groups. Compared with non-AKI group, the AKI group had more rash and lower limbs edema (P=0.017 and P=0.001), higher urine blood and protein positive rate (both P<0.001). Lower hemoglobin and serum albumin level (both P<0.001), worse clinical cardiac function (NYHA Ⅲ-Ⅳ, P=0.033) were found in AKI group compared with non-AKI group. There was no significant difference in microbiologic positive rate and pathogenic bacteria sorts between the two groups. Nine patients refused surgery, and the other 91 cases underwent cardiac surgery with cardiopulmonary bypass under general anesthesia, including 19 cases of AKI group and 72 cases of non-AKI group. The ventilation time and intensive care unit (ICU) stay time were longer in AKI group than in non-AKI group (P=0.028 and P=0.003). AKI group needed more red blood cell transfusion (P=0.010). Using the last serum creatinine before surgery as basic level, there was more new-onset AKI cases in AKI group than in non-AKI group. During the median follow-up time 42 months, there was no significant difference in perioperative and follow-up mortality between the two groups (P=0.463 and P=0.581).Conclusion: More perioperation complications occurred in IE patients with AKI, but no significant difference in in-hospital and follow-up mortality between the AKI and non-AKI groups was observed.

    Effects of thoracic epidural administration of lidocaine on hemodynamic and arousal responses of double lumen tracheal intubation during induction of anesthesia
    Kun-peng LIU,Bao-ning WANG,Yan-yan SHEN,Wei-xia LI,Zhao LI,Lan YAO
    2019, (4):  742-747.  doi: 10.19723/j.issn.1671-167X.2019.04.026    
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    Objective: To compare the effects of thoracic epidural administration of lidocaine on hemodynamic and arousal responses of double lumen tracheal intubation during induction of anesthesia. Me-thods: In the study, 40 patients with American Society of Anesthesiologists (ASA) physical statuses Ⅰ-Ⅱ,aged 19-66 years,scheduled for elective thoracic surgeries under general anesthesia requiring orotracheal intubation were allocated to either the double-lumen endobronchial intubation (T group) or double-lumen endobronchial intubation after epidural administration of lidocaine (E group). After an intravenous anesthetic induction, the orotracheal double-lumen intubation was performed using a Macintosh direct laryngoscopy (MDLS),respectively. Invasive blood pressure (BP),heart rate (HR) and bispectral index (BIS) were recorded before and after anesthetic induction,immediately after intubation and 5 minutes after intubation with 1-minute interval and the intubation time also noted. The rate pressure pro-duct (RPP) was calculated.Results: After anesthetic induction,BP and RPP in the two groups decreased significantly compared with their preinduction values. In comparison with their postinduction values, the orotracheal intubation in the two groups caused significant increases in BPs, HRs and RPP. In comparison with their preinduction values, BPs decreased significantly in E group, systolic blood pressure (SBP), diastolic blood pressure (DBP) and mean arterial pressure (MAP) increased significantly and lasted for 1 min in T group. The HRs of both groups after intubation were significantly higher than their baseline values,and increased in HR and lasted for 1 min and 4 min in E group and T group, respectively. SBP, DBP, MAP, HR and RPP after intubation in T group were significantly higher than those of E group during the observation period. The values of BIS were similar between both the groups. In T group, the incidences of SBP percent increased>30% of the baseline value and RPP more than 22 000 were significantly higher than in E group. None of the patients in group E had SBP more than 130% of the baseline value and RPP more than 22 000.Conclusion: During double-lumen endobronchial intubation, epidural administration of lidocaine can provide less hemodynamic response and similar arousal response.

    Delayed diagnosis of oral squamous cell neoplasms at different sites
    Tao XU,Dian-can WANG,Xiao-feng SHAN,Zhi-gang CAI
    2019, (4):  748-752.  doi: 10.19723/j.issn.1671-167X.2019.04.027    
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    Objective: To investigate the diagnostic delay of patients with oral squamous cell carcinoma by self-designed questionnaire to find out the significant influencing factors, so as to identify the influencing factors of the patient’s delay and the risk of oral cancer.Methods: A total of 514 patients with primary oral squamous cell carcinoma were enrolled at Peking University School and Hospital of Stomatology from January 2014 to April 2016, including 334 men and 180 women, with a male to female ratio of 1.85 :1. The youngest participant was 21 years old, with a maximum of 89 years and a median age of 57.6 years. The position of the disease according to International Classification of Diseases-10 (ICD-10) was divided into lip, buccal, gingival, retromolar, palate, floor of the mouth, tongue, and oropharynx. The age group is divided into 10 years. The level of education was divided into illiteracy, primary education level and advanced education level. Body mass index (BMI) was divided into three levels by 18 kg/m 2 and 25 kg/m 2. Visual analog scale (VAS) method was to evaluate the patient’s preoperative pain. At the same time, the patients were examined by detailed questionnaire to understand the delay factors and delay characteristics, and use SPSS 18.0 software, analysis of variance and chi-square test to explore correlation.Results: Among all patients, the proportion of patients developed in the tongue was the highest (43.3%). Delay was defined by a span of three months or longer from the onset of symptoms until treatment. The delays to diagnosis according to location were as follows (in months and in descending order): lip (6.1 months), buccal (4.1 months), floor of the mouth (3.9 months), tongue (3.6 months), oropharyngeal (2.9 months), retromolar (2.7 months), palatine (2.4 months), and gingival (2.4 months). Different sites and delayed diagnosis were statistically significant (P=0.048). There were no statistically significant differences in gender, education, pain, smoking, drinking and VAS score.Conclusion: The study has found that tumor positions and delay have a significant correlation. The position of the tumor is an obvious factor associated with the findings. The lip is the most likely to delay the diagnosis of oral positions. For the lip of the lesion, more than three months’ obvious mass is recommended for timely treatment, while at admission, physicians should take the appropriate diagnostic method as soon as possible.

    Construction of swept source optical coherence tomography imaging system for root canal endoscopy and application in diagnosis of root fractures
    Li-yuan QI,Chen CHEN,Lan JIANG,Jia-nan LI,Yu-hong LIANG
    2019, (4):  753-757.  doi: 10.19723/j.issn.1671-167X.2019.04.028    
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    Objective: To construct swept source optical coherence tomography (SS-OCT) imaging system for root canal endoscopy,and to evaluate the accuracy of diagnosing artificial root fractures.Methods: An ultra-high-speed (40 kHz) swept laser source was developed based on the piezoelectric tuning filter and the Fourier domain mode locking (FDML) swept laser technology (patent number: 200620135940.2). Ultra-miniature gradient index lens technology (patent number: 201320241218.7) was used to create a thin endoscopic probe with a diameter of 0.86 mm for real-time image transmission. The SS-OCT light source had a wavelength of 1 310 nm and a bandwidth of 100 nm. The axial and transverse image resolutions were 15 μm and 25 μm,respectively. Artificial fractures were created on human mandibular premolars with single root and the premolar roots were prepared to 41 horizontal sections (1 mm thick). 27 root sections with fractures (width: 52-284 μm) and 14 the sections without fractures were observed under an optical stereomicroscope with a cold light source as the gold standard. The horizontal root sections were scanned by self-developed SS-OCT imaging system for root canal endoscopy with a central wavelength of 1 310 nm and bandwidth of 100 nm. The data were reconstructed with 30 μm thick slices at an interval of 30 μm. Two observers,a radiologist and an endodontist,were trained and independently evaluated all the reconstructed images blindly. The diagnostic performance of SS-OCT imaging system was calculated,and statistical analysis was performed.Results: SS-OCT root canal endoscopic imaging system composed of high-speed swept laser source, fiber coupler, endoscopic probe, reference arm and differential detector. Root sections could be scanned by SS-OCT and imaged in realtime at a depth of 1 to 2 mm. The kappa value for interobserver agreement was 0.792,and the intraobserver agreement was 1.000 and 0.709 for two observers respectively. All of 27 fractured root sections and 12 of 14 root sections without fractures were accurately diagnosed while 2 unfractured root sections were misdiagnosed. The sensitivity was 1.000 and the specificity was 0.857 for diagnosis of artificial root fractures by SS-OCT. The positive predictive value (PPV),negative predictive value (NPV) and the overall accuracy rate were 0.931,1.000 and 0.951 respectively.Conclusion: The swept source optical coherence tomography imaging system for root canal endoscopy is a promising imaging method for observing root fractures.

    Application of totally extraperitoneal renal autotransplantation with Boari flap-pelvis anastomosis in upper urinary tract urothelial carcinomas treatment
    Si-da CHENG,Wan-qiang LI,Li MU,Guang-pu DING,Bo ZHANG,Cheng SHEN,Ze-wei YING,Kun-lin YANG,Han HAO,Xue-song LI,Li-qun ZHOU
    2019, (4):  758-763.  doi: 10.19723/j.issn.1671-167X.2019.04.029    
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    Objective: To evaluate the feasibility and effectiveness of the totally extraperitoneal renal autotransplantation with boari flap-pelvis anastomosis in the treatment of upper urinary tract urothelial carcinoma (UTUC), and to review the experience of renal autotransplantation for UTUC treatment. Me-thods: One case of applying the totally extraperitoneal renal autotransplantation with boari flap-pelvis anastomosis to the UTUC treatment was reported, and related literature was reviewed. The patient was a sixty-four-year old man who received right radical nephroureterectomy for right ureteral carcinoma 1 year before and diagnosed as left ureteral carcinoma(G2, high grade) this time. In order to preserve his renal function and avoid the shortness of common kidney-sparing surgery, a totally extraperitoneal procedure, including retroperitoneoscopic nephrectomy, ureterectomy, renal autotransplantation and Boari flap-pelvis anastomosis, was performed to the patient.Results: The operation was completed successfully without perioperative complications. The renal function recovered to preoperative level within 1 week. No deterioration of renal function during the follow-up and no tumor recurrence was observed under cystoscopy at the 3-month postoperative consult.Conclusion: The totally extraperitoneal renal autotransplantation with Boari flap-pelvis anastomosis is a feasible and effective treatment for UTUC. The innovative procedure has several advantages compared to the former ones. The extraperitoneal procedure results in significantly less pain, shorter hospital stay, decreased overall time to recovery and lower bowel complications risk without warm ischemia time extension. Meanwhile, the Boari flap-pelvis anastomosis simplifies the follow-up protocols and creates an easy route for cystoscopy and topical therapy. From the systematic clinical analysis, as well as the related literature review, it’s been concluded that the renal autotransplantation can be a reasonable option for the patients who have UTUC in solitary kidney or have bilateral UTUC. This type of treatment possesses advantages of preservation of renal function and total resection of malignant lesions. But long-term data and large cohort study on renal function or tumor recurrence are still absent which will be necessary to confirm the advantages of this approach.

    A case of gastric duplication presenting as a retroperitoneal cystic lesion
    Lu-ping YU,Qing LI,Shi-jun LIU,Huan-rui WANG,Tao XU
    2019, (4):  764-768.  doi: 10.19723/j.issn.1671-167X.2019.04.030    
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    Gastric duplication is a rare congenital anomaly accounting to 4% of all gastrointestinal tract duplications. It is usually diagnosed pre-natally or during infancy. Retroperitoneal gastric duplication is very rare in adult patients. It is generally asymptomatic or presents with non-specific symptoms. The sensitivity of classical imaging modalities for retroperitoneal gastric duplication is weak. Retroperitoneal gastric duplication could be misdiagnosed as other retroperitoneal cystic lesions and it could be definitely diagnosed by typical findings of abdominal enhanced computed tomography (CT) and endoscopic ultrasonography (EUS) plus EUS:guided fine needle aspiration biopsy in gastric duplicated cyst. A female adult patient was diagnosed by an exceptional hospital CT as retroperitoneal cystic lesion and was admitted in our hospital in March 2019. The abdominal enhanced CT in our hospital preoperatively indicated a cystic lesion above the left kidney and the maximum cross section was 9.0 cm ×5.2 cm. Lymphocysts and others should be identified and the lesion might be from the stomach. The retroperitoneal gastric duplication was not diagnosed before operation. In the operation laparoscopy revealed the cystic lesion in the retroperitoneum. The pancreas, left adrenal gland, and left kidney were compressed by the cystic lesion. The top of the lesion was connected with the small curvature of the stomach, but it was not communicated with the stomach. The retroperitoneal cystic lesion was completely excised and the surrounding organs were not damaged. The retroperitoneal gastric duplication was clearly diagnosed by the findings in the operation and the pathology of the lesion. The patient was discharged a week after surgery without gastrointestinal and pancreatic injuries. Therefore, the differential diagnosis of retroperitoneal cysts should consider the possibility of retroperitoneal gastric duplication. For patients with typical CT findings or unclear boundaries between the tumor and the stomach wall, gastric duplication could be diagnosed by EUS plus EUS:guided fine needle aspiration biopsy in the cyst. Retroperitoneal gastric duplication cyst could be completely excised by laparoscopy through abdominal cavity and the stomach wall could be completely repaired.

    Superficial siderosis of the central nervous system caused by myxopapillary ependymoma of conus medullaris and cauda equine: a case report and literature review
    Li XU,Ming-jie HU,Yu-yu LI,Hong-dang QU,Wei-dong QIAN,Xiao-lin LIU
    2019, (4):  769-774.  doi: 10.19723/j.issn.1671-167X.2019.04.031    
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    Superficial siderosis of the central nervous system (SSCNS) is a rare disorder caused by hemosiderin deposits in the subpial layers of the brain and spinal cord due to prolonged or recurrent low-grade bleeding into the cerebrospinal fluid (CSF). Central nervous system tumor could be one of the sources of bleeding. Some problems exist at present regarding the diagnosis and treatment of SSCNS in China. On account of fewer cases, the insufficient awareness of the condition, and the lack of long-term follow-up data, enough attention has not been paid to etiological diagnosis. The speculative high rate of missed diagnoses of SSCNS indicates a great disparity in the treatment from the world’s advanced level. Related data of clinical and basic research need to accumulate as soon as possible to promote the clinical diagnosis and treatment of the disease. The progressive neurological deficits are involved in the typical clinical manifestations of SSCNS with a triad of bilateral symmetrical sensorineural hearing loss, cerebellar ataxia and signs of corticospinal tract dysfunction. Nevertheless, there are few patients with the triad signs at the same time, which lead to a delayed diagnosis or misdiagnosis. Detection of this disease was commonly post-mortem until the advent of MRI with signal and location characteristics, which made diagnosis easier. Siderosis appears as a hypointense rim covering the surface of the cerebellum, the brain stem, the spinal cord, similar to a black pencil line, thin on SE-T2-weighted images, thick and cons-picuous on GE-T2-weighted images or on susceptibility-weighted imaging (SWI). The only effective way of treating the disorder is to identify the source of bleeding and remove it. MR examination is useful for seeking a source of bleeding too. Therefore, once superficial siderosis is considered, lesions of the central nervous system must be searched using MRI of the brain and spine. We report here a 37-year-old male diagnosed of SSCNS with the classical clinical symptoms of cerebellar ataxia, sensorineural hearing loss and myelopathy. T2-weighed MRI showed characteristic marginal hypo-intensity around the central nervous system. Etiological explorations revealed a large conus medullaris / cauda equina ependymoma filling the lumbosacral spinal canal, a myxopapillary ependymoma (MPE) confirmed by surgical resection and histopathological examination. The related literature was reviewed to ascertain the mechanism of SSCNS secondary to MPE, and to discuss the pathogenesis, clinical features, diagnosis and treatment of SSCNS. This paper aims to improve the awareness of SSCNS and diagnostic level, and to lay stress on the etiological explorations that is beneficial to the development of exact treatment plan.

    Guillain-Barre syndrome complicated on post-operation with renal carcinoma and meningioma: a case report
    Shuai XU,Yang-shuo WANG,Shu LI,Hai-ying LIU
    2019, (4):  775-777.  doi: 10.19723/j.issn.1671-167X.2019.04.032    
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    Guillain-Barre syndrome (GBS) is an autoimmune disease on the injury of peripheral nerve myelin proteins or axon, of which the acute motor axonal neuropathy (AMAN) as a subtype is of infrequence and an extremely low incidence of post-operation. This article originally reported one case from Peking University People’s Hospital on successful treatment of severe GBS (AMAN) on post-operation with renal carcinoma and meningioma. The diagnostic criteria of AMAN refer to AIDP, of which the feature of AMAN suggests a pure motor nerve dysfunction and significant damage on motor axon. It is reported that infection and surgery may induce GBS. The positive result of IgM and IgG was considered the application of ganglioside and blood-brain barrier might be damaged after meningioma surgery which eased the drug to enter the cerebrospinal fluid circulation and induced lesions, therefore the etiology on this GBS case was of high confidence of administrating ganglioside drugs. Autonomic nerve dysfunctions, such as blood pressure fluctuations and arrhythmia could be caused in GBS, of which about 3%-10% of GBS patients would die. Early use of gamma globulin or plasma exchange was recommended interna-tionally, but recently some new ideas, to some extent, of significance on GBS treatment emerged. However, there was still no consensus on GBS treatment systematically all over the world. Till now, the general treatment program on GBS may be still gamma globulin or plasma exchange and a curious judgment of prognosis is essential in order to make a reasonable plan. That it was usually of no omen on severe autonomic nerve dysfunction must be successively monitored, the same as the management of the respiratory tract and nutrition support. The key measures taken on lung recruitment was postural drainage on this case with a low cost but a qualified effectiveness. This case report aimed to deepen the understanding of AMAN and acquaint the cutting-edge advances on the treatment of GBS, as well as providing successful treatment experience for the prevention on similar cases.

    Appllication of human acellular dermal matrix in surgical treatment of genitourinary disease
    Zhong-cheng XIN,Bi-cheng YANG,Meng LI,Yi-ming YUAN,Wan-shou CUI,Yuan TANG,Dong FANG,Wei-dong SONG
    2019, (4):  778-782.  doi: 10.19723/j.issn.1671-167X.2019.04.033    
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    Humanacellular dermal matrix (HADM) is widely used in the field of burn wound repair and tissue engineering plastic surgery. HADM is manufactored by physical and chemical decellular process to remove the antigenic components that might cause immune rejection in dermis.The extracellular matrix of three-dimensional cell scaffold structure with collagen fibers had been used for wound repair and tissue regeneration, while HADM characterized with low absorption rate after implantation and strong ability to induce angiogenesis in host tissue. Studies reported that after the HADM was implanted into the patient, the host cells, such as fibroblasts and myofibroblasts, as well as lymphocytes, macrophages, granulocytes and mast cells, rapidly infiltrated the graft. The connective tissue and neovascularization were then formed within the HADM three-dimensional cell scaffold, the lymphatic system also appears after vascular reconstruction. Traditional urethral reconstruction using autologous skin flaps has some defects, such as complexity of the technology, risk of necrosis of the skin flaps after transplantation, and failure to achieve functional repair of the urethral epithelium. It has been reported that using HADM to reconstruct the urethra in patients with urethral stricture, hypospadias and bladder-vaginal fistula, showed promising results. Others have reported the experience of using HADM to repair and reconstruct congenital classic bladder exstrophy. HADM has also been used for tissue repair in patients with penile skin defect caused by Fonier’s gangrene and hidradenitis suppurativa, and implanted under Bucks’ fascia to enlarge the penis. The report of HADM implantation for treating premature ejaculation also deserves attention. Researchers found that HADM implantation can form a tissue barrier between the skin and corpus cavernosum, which can effectively reduce penile sensitivity and treat premature ejaculation. The safety and effectiveness of HADM implantation in the treatment of premature ejaculation need to be further standardized by data from multi-center, large-sample clinical studies. In summary, HADM is the extracellular matrix and three-dimensional cell scaffold of human dermis. As a new type of tissue repair material, new blood vessels are formed actively after implantation, which shows good histocompatibility. HADM has shown increasingly broad application prospects in treatment of genitourinary diseases including penis, urethra and bladder diseases. HADM has also been used in the treatment of premature ejaculation in recent clinical studies, and its long-term safety and efficacy need to be further investigated.

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