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In 2022, World Health Organization (WHO) launched the 5th edition of the classification of renal tumors. This classification continues to use the previous classification framework of renal tumors based on morphology and tissue structure, and proposes the concept of renal cell carcinoma defined by molecular features for the first time. This article interprets from the 3 aspects of historical changes of WHO classification and grading of renal tumors, comparison of 2022 and 2016 WHO classification of renal tumors, and the role of molecular characteristics in the new pathological types such as ELOC mutant renal cell carcinoma, ALK rearrangement renal cell carcinoma, eosinophilic solid and cystic renal cell carcinoma. The purpose is to better understand the WHO from the traditional classification system based on tissue morphology to a three-in-one integrated classification system covering morphology, immunophenotype and genetic characteristics, and to understand the important value of molecular pathology in guiding the work of pathologists and clinicians under the new classification system.
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Objective:To explore the effect of enhanced recovery after surgery (ERAS) protocols in patients undergoing laparoscopic radical cystectomy (LRC) and intracorporeal urinary diversion (ICUD).Methods:A total of 83 patients who received LRC+ ICUD in Beijing Chaoyang Hospital from March 2014 to September 2020, were divided into 2 groups based on different perioperative management, including 29 ERAS cases and 54 conventional recovery after surgery (CRAS) cases. The ERAS group included 26 males and 3 females , with an average age of (62.07 ± 9.26) years. There were 26 patients with ASA class Ⅰ-Ⅱ, 3 patients with ASA class Ⅲ, 4 patients received neoadjuvant chemotherapy, and 7 patients had a history of abdominal surgery in ERAS group. The CRAS group included 44 males and 10 females , with an average age of (61.59 ± 10.16) years. There were 50 patients with ASA class Ⅰ-Ⅱ, 4 patients with ASA class Ⅲ, 9 patients received neoadjuvant chemotherapy, and 10 patients had a history of abdominal surgery in CRAS group. There were no statistically significant differences in the baseline characteristics between the two groups. The patients in both groups underwent LRC+ ICUD procedures. The perioperative results and complications between the two groups were compared.Results:In the ERAS group, there were 20 patients who underwent Bricker ileal conduit surgery and 9 patients who underwent Studer orthotopic ileal neobladder surgery. Pathological staging included 3, 3, 7, 7, 5 and 4 cases in stage T a, T is, T 1, T 2, T 3 and T 4a, respectively. There were 23, 2, 3 and 1 patient with pathological stage N 0, N 1, N 2 and N 3, respectively. Pathological diagnosis included 3 cases of low-grade urothelial carcinoma, 24 cases of high-grade urothelial carcinoma, and 2 cases of other histological subtypes. In the CRAS group, there were 31 patients who underwent Bricker ileal conduit surgery and 23 patients who underwent Studer orthotopic ileal neobladder surgery. Pathological staging included 5, 3, 12, 9, 15 and 10 patients in stage T a, T is, T 1, T 2, T 3 and T 4a, respectively. There were 35, 6, 7 and 6 patients with pathological stage N 0, N 1, N 2, and N 3, respectively. Pathological diagnoses included 6 cases of low-grade urothelial carcinoma, 45 cases of high-grade urothelial carcinoma, and 3 cases of other histological subtypes. There were no statistically significant differences ( P>0.05) in surgical methods, pathological staging, or pathological types between the ERAS and CRAS groups. ERAS group presented less albumin loss [(25.73±8.63)% vs. (32.63±9.05)%, P=0.001], shorter hospital stay [9(7, 13)d vs. 12(9, 16)d, P=0.006], less 30-day overall complications [55.2% (16/29) vs. 83.3% (45/54), P=0.009]. In multivariable analysis, maximum albumin loss≥20% was independently associated with 30-day minor complications ( P=0.049), and maximum albumin loss ≥25% was independently associated with hospital of stay≥10 days ( P=0.038), respectively. Conclusions:For patients who received LRC+ ICUD, ERAS was associated with reduced perioperative albumin loss, shorter length of stay, less 30-day complications, accelerated recovery time, improved clinical outcome and less albumin injection.
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Objective:To evaluate the clinical value of Xing's ureteroileal anastomosis technique in radical cystectomy.Methods:The data of 38 patients who underwent radical cystectomy with Xing's ureteroileal anastomosis technique at Cancer Hospital, Chinese Academy of Medical Sciences and Beijing Chaoyang Hospital from July 2013 to June 2021 were retrospectively reviewed. There were 30 males and 8 females. The mean age was 61.6±15.1 years old. The mean body mass index (BMI) was 25.1±2.7 kg/m 2. The American Society of Anesthesiology (ASA) graded 25 cases as grade 1, 10 cases as grade 2 and 3 cases as grade 3. There were 35 cases with stage cT 2N 0M 0 and 3 cases with cT 3N 0M 0. All patients underwent radical cystectomy and ileal conduit, and the ureteroileal anastomosis was performed using the Xing's ureteroileal anastomosis technique. Afferent loop entry was divided equally into two lumens. After 1.5 cm-long lengthwise incisions, each ureter was directly and end-to-end anastomosed to the aforementioned lumens. Postoperative information was recorded, including ureteric stricture, ureteric reflux, hydronephrosis, anastomotic leakage, renal calculus, urinary tract infection, and pyelonephritis. Results:Ureteroileal anastomosis was performed successfully in 38 cases with 76 units. The median follow-up time was 35.6 (17.0, 46.3) months. Three patients developed unilateral anastomotic stenosis after operation. Five patients had unilateral ureteral reflux. Two patients had unilateral hydronephrosis. No anastomotic leakage, urinary tract infection, or pyelonephritis occurred after the operation. Renal calculus appeared in 3 cases, all on the left unit.Conclusions:Xing's ureteroileal anastomosis technique is a simple method with few postoperative and good functional outcomes.
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Fluorescence-guided surgery (FGS) with tumor-targeted imaging agents, particularly those using the near-infrared wavelength, has emerged as a real-time technique to highlight the tumor location and margins during a surgical procedure. For accurate visualization of prostate cancer (PCa) boundary and lymphatic metastasis, we developed a new approach involving an efficient self-quenched near-infrared fluorescence probe, Cy-KUE-OA, with dual PCa-membrane affinity. Cy-KUE-OA specifically targeted the prostate-specific membrane antigen (PSMA), anchored into the phospholipids of the cell membrane of PCa cells and consequently showed a strong Cy7-de-quenching effect. This dual-membrane-targeting probe allowed us to detect PSMA-expressing PCa cells both in vitro and in vivo and enabled clear visualization of the tumor boundary during fluorescence-guided laparoscopic surgery in PCa mouse models. Furthermore, the high PCa preference of Cy-KUE-OA was confirmed on surgically resected patient specimens of healthy tissues, PCa, and lymph node metastases. Taken together, our results serve as a bridge between preclinical and clinical research in FGS of PCa and lay a solid foundation for further clinical research.
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Objective:To investigate the trend of prostate cancer incidence in Chinese tumor registration areas between 1988 and 2015.Methods:Collect the data including number of males, prostate cancer incidence rate and age-standardized incidence rate by world standard population(ASIRW) in Chinese tumor registration areas between 1988 and 2015. Calculate the average annual increase rate, and evaluate the trend of changes in the incidence of prostate cancer in China.Results:From 1988 to 2015, the number of male population covered by Chinese tumor registration areas increased from 10.41 million to 162.76 million, an average annual increase of 10.72%.The incidence of prostate cancer increased from 1.71 per 100 000 to 10.39 per 100 000, with an annual percentage change of 6.91%. The ASIRW increased from 1.82 per 100 000 to 6.05 per 100 000, with an average annual increase of 4.55%. In 1988—1997, 1998, 1999—2008, 2009—2010, and 2011—2015, the average annual increase rate of the male population covered by Chinese tumor registration areas was 0.99%, 36.73%, 7.92%, 37.55%, and 20.88% respectively. The average annual increase rate of prostate cancer incidence was 8.43%, -0.75%, 12.08%, -9.74%, 3.01%, and the average annual increase rate of ASIRW was 5.94%, -6.01%, 8.88%, -7.04%, 0.78%, respectively.Conclusions:The incidence of prostate cancer in Chinese tumor registration areas increased gradually during the early era of epidemiological investigation, followed by a rapid increase and a subsequent mild increase. With the rapid changes in the national cancer registration area and the population covered, the incidence of prostate cancer has declined in a short period of time.
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Objective:To investigate the clinical effect and demonstrate the techniques of single position laparoscopic nephroureterectomy.Methods:The clinical data of 84 upper urinary tract urothelial carcinoma patients admitted to the Cancer Hospital Chinese Academy of Medical Sciences from September 2018 to July 2022 were retrospectively analyzed, including 39 males and 45 females, with a median age of (64.9±9.3)years and mean BMI of(24.7±3.4)kg/m 2. The tumor was located on the left side in 47 cases and the right side in 37 cases. All 84 patients received single position laparoscopic nephroureterectomy. According to different treatment methods, they were divided into two groups, including 67 cases undergoing nephrectomy first, and then bladder cuff excision was performed along ureter(traditional group), 17 cases undergoing bladder cuff excision before clamping the ureter below the tumor, and then nephrectomy was performed along the ureter to the head side (modified group). There was no statistically significant in the comparison of age [(65.5±9.4)years vs.(62.7±8.9)years], BMI[(24.9±3.5)kg/m 2vs.(23.9±3.3)kg/m 2], left/right side tumor of(38/29 cases vs. 9/8 cases), tumor location (in renal pelvis or calyx or upper/middle/lower ureter being 46/9/12 cases vs. 13/2/2 cases)and tumor stage(T 1-2/T 3-4: 54/13 cases vs. 15/2 cases) between traditional group and modified group ( P>0.05). The operation time, estimate blood loss, postoperative intestinal function recovery time and postoperative drainage time were recorded and compared. Results:All 84 cases were successfully completed without conversion to open surgery. The mean operation time was (160.4±50.1)min, the mean estimated blood loss was(59.4±24.4)ml, the median postoperative intestinal function recovery time was 1(1, 2)d and the mean postoperative drainage time was (4.8±1.9)d(No drainage tube was placed in 4 patients). No Clavien Dindo >grade 3 complications occured. There was no significant difference in the comparison of operation time [(159.2±52.9)min vs. (164.7±38.1)min], estimate blood loss [(60.5±26.2)ml vs. (55.0±17.5)ml], postoperative intestinal function recovery time [1(1-2)d vs. 2(1-2)d] and drainage removal time [(4.8±1.8)d vs. (5.2±2.0)d] between traditional group and modified group ( P>0.05). The postoperative pathology of 84 cases was urothelial carcinoma, and the pathological results of the resection margin were negative. The median follow-up of 84 upper tract urothelial carcinoma patients was 13(3, 28)months. Five patients were lost to follow-up. In traditional group, 5 patients had bladder tumor recurrence, and 5 patients had distant metastasis. In modified group, no bladder tumor recurrence occurred and 1 patient had distant metastasis. Conclusions:Laparoscopic nephroureterectomy in single position is a safe and effective minimally invasive technique for the treatment of upper urinary tract urothelial carcinoma. Treatment of the bladder cuff excision firstly is more in line with the principle of tumor-free and increase surgical space.
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Objective:To explore risk factors for positive surgical margin (PSM) after laparoscopic radical prostatectomy (LRP) in high risk prostate cancer (PCa) patients with and without neoadjuvant hormornal therapy (NHT).Methods:The clinicopathological data of 202 high risk patients who underwent LRP from January 2012 to July 2020 was retrospectively analyzed. There were 111 cases performed in Beijing Chaoyang Hospital and 91 cases in National Cancer Center. Mean age was(67.7±6.5)years, mean BMI was (25.65±3.21)kg/m 2. Median highest preoperative PSA was 20.97(11.00, 34.40)ng/ml, median preoperative prostate volume was 32.88(23.33, 46.20)ml. Among all 202 high risk PCa patients, 97 did not receive NHT(non-NHT group) and 105 received NHT(NHT group). There were significant statistical difference in term of highest PSA, preoperative prostate volume between NHT and non-NHT groups ( P<0.05), while there was no significant difference in term of age or BMI between the two groups. Among NHT patients, 80 cases accepted complete androgen blockade therapy with median course of 3 months; 3 cases accepted simple castration therapy with median course of 3 months; 22 cases accepted simple anti-androgen therapy with median course of 1 month. Risk factors for PSM after LRP in NHT and non-NHT groups were respectively explored, including age, BMI, hypertension, diabetes, history of pelvic surgery, highest PSA before puncture, ISUP before puncture, preoperative prostate volume, ISUP after LRP, postoperative pathological stage T, pathological lymph node involvement, vessel carcinoma embolus, etc. Results:PSM rate was 50.5%(49/97) and 24.8% (26/105) in non-NHT and NHT, respectively. The apex was the most common location of PSM in non-NHT group(35.1%, 34/97), while the fundus was the most common location of PSM in NHT group(14.3%, 15/105). Multiple logistic regression revealed that postoperative pathological stage T was the only independent factors affecting the PSM for high risk patients without NHT ( OR=3.814, 95% CI 1.302-11.173, P=0.015), while postoperative pathological stage T, pathological lymph node involvement, and vessel carcinoma embolus were independent risk factors affecting PSM for high risk patients with NHT ( OR=18.434, 95% CI 4.976-68.297, P<0.001; OR=7.181, 95% CI 2.089-24.689, P =0.002; OR=3.545, 95% CI 1.109-11.327, P=0.033). Conclusions:Postoperative pathological stage T was independent risk factors affecting PSM for all high risk PCa patients no matter with or without NHT, while pathological lymph node involvement, and vessel carcinoma embolus were also independent risk factors affecting PSM for high risk PCa patients with NHT.
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Objective:To analyze the learning effect of laparoscopic radical cystectomy(LRC)+ modified ileal conduit(MIC).Methods:From 2014 to 2019, 42 patients underwent MIC and their clinical data was retrospectively analyzed. 34 operations were performed by surgeon 1 and 8 operations by surgeon 2. We divided the 34 patients of surgeon 1 into three groups according to their surgical sequence (group A, 1st to 12th; group B, 13th to 23th; group C, 24 th to 34 th), the 8 cases of surgeon 2 was regarded as group D. The history of abdomen surgery in the 4 groups were 0, 1, 4, 3 cases, respectively ( P<0.05). There was no significant difference of the other baseline characteristics, such as age, BMI, American Society of Anesthesiologists. Then we compared several variables between the 4 groups like operation time, time of ileal conduit construction, blood loss, complication rate, lymph node yield, surgical margin, etc. The key steps of the MIC included isolating terminal ileum when the mesentery was transilluminated, performing end-to-end reflux ureterointestinal anastomosis after the efferent loop was fixed, closing the rent of the retroperitoneum. Results:All operations were performed intracorporeally with no transition to open surgery. The operative time for group A, B, C were 330.0(320.0, 360.0)min, 300.0(250.0, 308.0)min, 270.0(216.0, 324.0)min, respectively ( P =0.010). The time of ileal conduit construction of the 3 groups were 136.5(131.3, 147.5)min, 92.0(79.0, 119.0)min, 79.0(72.0, 115.0)min, respectively ( P <0.001). In addition, the difference of the two variables above between A and B, A and C groups separately reached statistical significance ( P<0.05), while the difference between B and C groups did not ( P>0.05). Other variables, such as blood loss, complication rate, lymph node yield, surgical margin, between the 3 groups reached no statistical significance ( P>0.05). The operative time of group D was 420.0(350.0, 450.0)min, and it reached statistical significance ( P<0.05) when compared with group A. There were no significant differences in other variables, such as blood loss, complication rate, lymph node yield, surgical margin, among the 2 groups ( P>0.05). Conclusions:The learning effect of LRC+ MIC was obvious. When surgeon volume increased, the operative time decreased significantly. Variables like estimated blood loss and complication rate of the 2 surgeons did not reached significant difference, which indicated reproductivity and safety of this procedure.
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Objective:To evaluate the value of 68Ga-labeled prostate-specific membrane antigen( 68Ga-PSMA PET/CT)in the diagnosis of prostate cancer(PCa) and determination of the strategy on neurovascular bundle(NVB)preservation and lymphadenectomy before surgery. Methods:We retrospectively analyzed the clinical data of 46 patients with newly diagnosed PCa who underwent 68Ga-PSMA PET/CT from June 2018 to October 2019. The median age was 66.50 (60.00, 69.25) years old and the median PSA was 15.97(8.58, 33.10)ng/ml. Forty-one patients were diagnosed PCa and 5 were diagnosed with benign prostatic hyperplasia or prostatitis by 68Ga-PSMA PET/CT, 6 were diagnosed with lymph nodes metastasis. Forty patients underwent mpMRI, 33 were diagnosed PCa, and 6 were diagnosed with lymph nodes metastasis. Seventeen patients underwent 11C-choline PET/CT, 12 were diagnosed PCa, and 4 were diagnosed with lymph nodes metastasis. Among the 41 patients which were diagnosed PCa by 68Ga-PSMA PET/CT, 26 were confirmed with PCa by needling biopsy, 12 did not undergo the needling biopsy and 3 had negative biopsy; 22 were in the high-risk group, and 19 were in the low- and medium-risk group. All 41 patients underwent radical prostatectomy. The strategy of NVB preservation was determined by the position of the PCa reported by 68Ga-PSMA PET/CT. If the tumor was close to the unilateral prostate capsule, the healthy part of the NVB would be preserved. And if the tumor was limited in the prostate gland, bilateral NVB would be preserved. The NVB was preserved in 16 cases(6 cases unilateral and 10 cases bilateral). In addition to routine lymph node dissection for patients in the high-risk group, lymph node dissection was also performed on patients with 68Ga-PSMA PET/CT that showed positive lymph nodes in the low- and medium-risk groups. The paired chi-square or Fisher exact test was used to compare the sensitivity and specificity of 68Ga-PSMA PET/CT, mpMRI, and 11C-choline PET/CT for lesion detection. Spearman analysis was used to examine the correlation between the SUV max, Gleason score, and the PSA value before treatment. Results:Forty-one patients undergoing radical resection were diagnosed PCa by postoperative pathology, and no cancer tissue was observed at the surgical margin; the median Gleason score was 8(7, 9); 20 cases (48.8%) had a pathological stage ≤pT 2c; 21 cases (51.2%)≥pT 3; 7 cases were N+ (11 positive lymph nodes). Seven cases (17.1%) had complications of Clavien-Dindo ≤ grade 2 within 30 days after surgery, and there was no complication above grade 3 after surgery. The median follow-up time of the 41 patients was 16(12, 20). The rate of urinary control was 46.3%, 95.1%, and 100% after 1 month, 6 months, and 12 months follow-up respectively. Among the five patients that did not undergo surgery, the PSA value of 4 decreased after antibiotic treatment, and biopsy was performed in 1 case without PSA decreasing, and no carcinoma was found. The sensitivity of 68Ga-PSMA PET/CT on the primary PCa was 100%(41/41), which was significantly better than that of 11C-choline(80%, 12/15, P=0.016)and mpMRI (83.7%, 31/37, P=0.009), while no statistical significance was observed between the specificity of 68Ga-PSMA PET/CT (5/5)and 11C-choline PET/CT(2/2, P=1.000), 68Ga-PSMA PET/CT and mpMRI(1/3, P=0.107). Of the 41 patients that were diagnosed with PCa, the sensitivity of 68Ga-PSMA PET/CT to lymph nodes metastases(71.4%, 5/7) had a significant difference with that of mpMRI(16.7, 1/6, P=0.016), but no statistical difference with 11C-choline (75%, 3/4, P=1.000). Analysis of the relationship between SUV max of 68Ga-PSMA PET/CT, Gleason score, and PSA value before treatment revealed that the SUV max of 68Ga-PSMA PET/CT in patients with Gleason score ≥8 and <8 score were 19.60(9.58, 24.38) and 8.55 (5.18, 12.88); SUV max of patients with PSA values ≥20 ng/ml and <20 ng/ml before treatment were 19.40 (13.00, 23.50) and 8.40 (5.35, 13.95), respectively, the differences were statistically significant (all P<0.05). Conclusions:68Ga-PSMA PET/CT had high sensitivity and specificity for the diagnosis of primary prostate cancer lesions, but the sensitivity for the diagnosis of lymph node metastasis was not enough to guide the preoperative decision of whether to remove the lymph node and the scope of the removal. However, the treatment strategy of whether to retain NVB could be formulated according to the tumor location displayed by 68Ga-PSMA PET/CT before surgery.
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The guideline content of non-muscle invasive bladder cancer(NMIBC) by European Association of Urology has been updated in 2020, mainly included: ①Histological variant classification information of urothelial carcinoma has been added; ②The classification of BCG therapy failure has been revised; ③Immune checkpoint inhibitors has been approved for the treatment of BCG unresponsive high risk NMIBC. This paper is to introduce and summarize the main points of the updated guideline.
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Objective:To discuss the surgical techniques and clinical value of pure laparoscopic radical nephroureterectomy without changing patient’s position in the treatment of upper tract urothelial carcinoma(UTUC).Methods:The clinical data of 28 patients, who underwent pure laparoscopic radical nephroureterectomy with single patient’s position in the treatment of UTUC , were collected and analyzed, including 16 males and 12 females, with the median age of (68.3±9.7)(45-80)years.There were 20 renal pelvic carcinoma and 8 ureteral carcinoma with preoperative clinical TNM stage of T l-T 3N 0M 0. Among them, 9 tumors were located in right side, while 19 in left side. With the patient in a contralateral oblique position at 50°-70°. , an additional instrument hole is added at the midpoint between the umbilicus and pubic symphysis, besides the classical four holes. Nephrectomy was carried out routinely after the pneumoperitoneum was built, and then the ureter was dissected all the way down to bladder wall. The bladder was closed with 3-0 absorbable barbed suture following the bladder cuff being incised.The specimen were retrieved through the extended incision of the lower abdomen trocar or through vagina if suitable. There was no need to change patient’s positioning during operation. Results:All surgical procedures were successfully performed without conversion to open surgery. There was no serious bleeding or other operation related complications. The mean operative time was (136.3±48.7)(70-270)min, while the estimated blood loss was (46.3±38.3)(10-200)ml. The mean postoperative drainage volume (287.3±196.6)(30-910)ml, while the mean postoperative drainage time was 3.2(1-5)d. Their intestinal function recovered 1.5(1-4) d postoperatively. Their average postoperative hospital stay was(6.1±1.7)(3-12)d.Pathological results showed urothelial carcinoma in all cases, including 21 high grade and 7 low grade. Lymphovascular invasion was found in 7 cases of high-grade urothelial carcinoma. All the surgical margins were negative. The median follow-up was(9.2±4.8)(1-12)months, and there was neither tumor recurrence nor distant metastasis.Conclusions:Compared with the traditional operation method, single posture pure transperitoneal laparoscopic radical nephroureterectomy have the advantages of standardized operation method, simple procedure, less trauma, less bleeding and quick postoperative recovery. It is a safe and effective minimally invasive technology for the treatment of UTUC.
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Objective To explore the feasibility and clinical effect of laparoscopic radical cystectomy with intracorporeal Xing's orthotopic neobladder.Methods Forty-one patients who underwent laparoscopic radical cystectomy with intracorporeal Xing's orthotopic neobladder from July 2013 to August 2019.There were 31 cases performed in Beijing Chaoyang hospital and 10 cases in National Cancer Center.Mean age was 59 (range 44-78) years,mean BMI was 25.3 (range 20.1-34.7) kg/m2,and mean CCI was 3 (range 2-6).No urethral stricture or urinary incontinence was found by preoperative examination.No distant metastasis was identified by bone scans,chest X-ray and sonography.Cystoscopy or TURBT was performed on all patients and biopsy was taken to confirm the diagnosis.Preoperative pathology showed 30 cases (73.2％) of MIBC,9 cases of NMIBC (22.0％) and 2 cases (4.9％) of in-situ cancer.Laparoscopic radical cystectomy and lymphadenectomy were performed under general anesthesia.Urinary diversion was completed in the peritoneal cavity,by intercepting the terminal ileum about 60 cm,and taking the proximal ileum 10 cm as input loop on the right side with proximal to distal way,and the middle 40 cm ileum was detubated.After u-shaped suture,the ileum was folded back and stitched into a sphere building a novd orthotopic neobladder with bilateral isoperistaltic afferent limbs.The prognosis of perioperative data and postoperative satisfaction regarding continence were analyzed,continence was defined as 0-1 pad/day.The 41 patients were divided into two groups to compare the difference in term of operation time and blood loss between the first 21 patients and the last 20 patients.Results Mean total operative time was 324.9 mins (range 210-480) mins,and mean estimated blood loss was 177.6(range 50-700) ml.There were significant statistical differences in term of total operation time,construction time and blood loss between the first 21 patients and the next 20 patients (P ＜ 0.05).Postoperative pathological results were urothelial carcinoma in 40 cases (2 in situ carcinoma) and small cell carcinoma in 1 case.Mean number of dissected lymph nodes was 19 (range 11-58),with 7 cases(17.1％)of positive lymph nodes,and 3 cases(7.3％) had positive surgical margin.At a mean follow up of 17.6 (range 2-64) months,36 patients (87.8％) survived,including 2 patients (4.9％) with metastasis and 1 patient (2.4％) with recurrence,and 5 cases (12.2％)died.All patients were able to urinate without catheterization.Thirty-seven patients (90.2％) were satisfied with voiding control during the daytime (0-1 urinal pad),and 29 patients (70.7％) were satisfied with voiding control at nighttime (0-1 urinal pad) by the follow-up 12 months after the operation.Conclusions Total laparoscopic radical cystectomy combined with Xing's orthotopic ileum neobladder is a simple method with fewer postoperative complications and a satisfactory continence rate.
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Objective To discuss the effect and value of wrapping ureter by a pedicled gastrocolic omentum flap during cutaneous ureterostomy as urinary diversion after radical cystectomy.Methods The clinical data of 12 cases(7 males and 5 females)with bladder cancer during January 2016 and September 2017 were retrospectively analyzed.The median age was 77 years (range 75-83),and the course of the disease was 5 days to 2 years.11 cases had gross hematuria,5 cases had frequent and urgent urination,1 case had lower abdominal pain,and 1 case had no obvious clinical symptoms.9 cases had a history of transurethral prostatic resection.8 cases had a complication of hypertension,5 cases had a complication of diabetes,7 cases had a complication of cardiovascular and cerebrovascular diseases,and 6 cases had a complication of anemia.The ASA level was 3 in 9 cases and was level 4 in 3 cases.All the patiants were diagnosed of bladder urothelial carcinoma by biopsy.There were 8 cases with T3 tumor and 4 cases with T4.All the patients underwent laparoscopic radical cystectomy under general anesthesia,and wrapping ureter by a pedicled gastrocolic omentum flap during cutaneous ureterostomy was used for urinary diversion.Take a segment of 3-5 cm wide pedicle omentum,which is covered from the distal end of the ureter to the end,and use a 4-0 absorbable line to fix the omentum and ureteral outer membrane,and then perform ureterocutaneostomy.The incidence of postoperative anastomotic stenosis,hydronephrosis and wound infection were observed.Results All the operations were performed successfully without obvious operative complications.The mean operating duration was125 (95-217) mins,estimated volume of blood loss 120 (50-600)ml.5 days after surgery,1 patient developed incision infection,which was cured by strengthening anti-infection drug therapy and wound dressing.No complications such as urinary fistula,intestinal fistula and peripheral hernia occurred.No death was reported during perioperative period.Single J tube was removed 1-3 months after surgery.Within a follow-up of 12 (3-23) months,1 case died of cerebral infarction 3 months after surgery,1 case occurred papilla light constriction without special treatment,no ureteral stenosis and necrosis cases and there were no cases of hydronephrosis.All the patients were satisfied with the quality of life after surgery.Conclusions Wrapping ureter by a pedicled gastrocolic omentum flap during cutaneous ureterostomy is simple,safe and effective as urinary diversion after radical cystectomy.
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Objective To compare perioperative outcomes and complications between intracorporeal and extracorporeal orthotopic ileal neobladder after laparoscopic radical cystectomy (LRC) from one center.Methods We retrospectively analysis patients' clinical and follow-up data who underwent laparoscopic radical cystectomy (LRC) in our hospital from January 2011 to May 2017,of whom 25 cases underwent intracorporeal orthotopic ileal neobladder (ICIN) and 20 cases underwent extracorporeal orthotopic ileal neobladder (ECIN).The patients' characteristics,perioperative data,postoperative pathological results,postoperative complications and oncologic outcomes were compared and analyzed.The mean age of ECIN group was (59.9 ± 10.5)years,mean BMI was (24.7 ±3.3)kg/m2,the ASA level was less than Ⅱ in 19 cases and level Ⅲ in 1 case,the mean preoperative CCI was 4.5 ± 1.6,3 patients got preoperative neoadjuvant chemotherapy.The mean age of ICIN group was (59.0 ± 9.8) years,mean BMI was (25.3 ±4.3)kg/m2,the ASA level was less than Ⅱ in 25 cases and no level Ⅲ,mean preoperative CCI was 4.0 ±1.3,3 patients got preoperative neoadjuvant chemotherapy.There was no statistical difference between the two groups in patients' characteristics.All operations were performed under general anesthesia.After LRC was accomplished,an additional 12 mm trocar was placed 1 cm crania to the pubic symphysis for EndoGIA in ICIN group.An ileal segment 60 cm long was isolated 25 cm proximal to the ileocecum.The continuity of the small bowel was restored with side to side anastomosis.The proximal 10 cm was moved to the distal end of the ileal segment for the right isoperistaltic afferent limb,and the remaining proximal 10 cm ileal segment was reserved for the left isoperistaltic afferent limb.Then,the remaining length of the 40 cm ileal segment was detubularized along its antimesenteric border.The anterior wall of the neobladder was folded forward and the free edges were sutured to achieve a spherical configuration.After single J ureteric stents were inserted into the ureters,the urethra and ureters were sutured with neobladder successively.For ECIN,the ileal segment is removed via a midline laparotomy below the umbilicus 5-10 cm.The construction method of neobladder was the same with ICIN group.Results All 45 cases were successfully operated.There was no statistical difference between ICIN group and ECIN group in operation time [(374.2 ± 74.6) min vs.(360.3 ±83.6)min,P =0.557] and extraction time of pelvic drainage tube[(12.5 ±5.9)d vs.(11.8 ±4.5)d,P =0.686].Patients in the ICIN group had less intraoperative blood loss [(186.0 ± 140.3)ml vs.(272.0 ±110.7) ml,P =0.030],shorter oral intake time [(4.2 ± 2.2) d vs.(6.1 ± 1.6) d,P =0.002],shorter postoperative hospital stay [(13.7 ± 4.2) d vs.(19.9 + 7.6) d,P =0.001].There was no significant difference in the early postoperative complications (P =0.345).The median follow-up time of ICIN group and ECIN group were 30 months and 52.5 months,respectively.The day-time and night-time continence rate were 97.4％ and 86.8％ respectively in the first year after surgery without significant difference.A total of 6 patients suffered distant metastasis,of whom 4 patients suffered multiple metastases,1 case bone metastases and 1 case pelvic lymph node metastasis.Seven patients died,five of whom died of tumor recurrence or metastasis.There was no statistical difference between the two groups in cancer specific survival rates (P =0.644) and recurrence free survival rates (P =0.981).Conclusions Comparing with extracorporeal orthotopic ileal neobladder,intracorporeal orthotopic ileal neobladder has advantages of less blood loss and faster intestinal function recovery,without significantly increased operative time and complications.No significant difference was found in the function of neobladder and oncological outcomes.Randomized controlled trial with large sample and long-term follow-up is needed to verify the advantages of intracorporeal neobladder construction.
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Objective To discuss surgical tips and techniques of laparoscopic radical cystectomy in the female.Methods We retrospectively reviewed 29 females who underwent laparoscopic radical cystectomy between Feb.2008 and Mar.2017.The median age was 64 years (range 37-83 years),and the median BMI was 24.7 kg/m2 (range 12.1-31.2 kg/m2),and the median CCI was 3 (range 2-9).No distant metastasis was identified by bone scans,chest X-ray and sonography.Preoperative pathology were non-muscular infiltrating bladder cancer in 19 patients and muscular infiltrating bladder cancer in 10 patients by cystoscopic biopsy.Surgical method:under general anesthesia,the patients were placed in lithotomy position.A 5-port transperitoneal approach was used.Under laparoscopy,the suspensorium ligament of ovary was dissected and cut at lateral to the fimbriae of uterine tube,then the ureter was divided and umbilical artery was managed.The broad ligament of uterus was divided.Afterwards,the Douglas'pouch was opened and the fornix of vagina was cut transversely.Then,the endopelvic fascia was divided.The bladder was excised with the female reproductive organs together.If the female reproductive organs were decided to preserve,the dissection was performed along the space between bladder and uterus or vagina.Frozen section of urethra end andthe distal ureter were then obtained.The resected tissues were removed through the vagina,and then vagina was closed.Urinary diversion consisted of orthotopic ileal neobladder in 9 patients,ileal conduit in 14 patients,ureterostomy in 4 patients.All urinary tracts were removed for two cases due to renal function loss before surgery.Results Mean total operative time was 315 mins (ranged from180 mins to 420 mins).Estimated blood loss was 299 ml (ranged from 10 ml to 1 500 ml).Complications occurred in 2 cases.One patient had both vaginal infection and incomplete intestinal obstructionand the other had vaginal infection alone.No patients died in perioperative period.At a median follow up of 36.8 months (ranged from 2 to 110 months),24 patients (82.8％)were alive without recurrences,1 (3.4％) had metastasis in lymph nodes and 4 (13.8％) died.Conclusions Laparoscopic radical cystectomy in the female is technically feasible.Knowing female pelvic anatomy and grasping the techniques conduce to optimize the tips of the surgery and reduce complications.
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Objective To explore the perioperative outcomes and safety of enhanced recovery after surgery (ERAS) in laparoscopic radical cystectomy (LRC).Methods We retrospectively evaluated outcome of 10 LRC patients on ERAS protocol from May 2017 to October 2017,and 39 LRC patients on conventional recovery after surgery(CRAS) protocol from July 2015 to November 2016.There were (60.9 ±11.4) years and (63.7 ± 12.1) years in ERAS group and CRAS group respectively(P =0.514);(25.5 ±2.7) kg/m2 and (24.4 ± 3.6) kg/m2 with body mass index (P =0.375).Both of the median of charlson comorbidity index (P =0.931) and American Society of Anesthesiologists score (P =0.254) were 2 There was no statistical significance between the two groups for type of urinary diversion and preoperative laboratory studies (P ＞ 0.05).Patients' perioperative outcomes,early (30-day) complications and postoperative readmission rate were compared.Results The ERAS group had less intraoperative crystalloid infusion [(950.0 ± 474.3) ml vs.(1 797.4 ± 448.1) ml,P ＜ 0.001],faster removed gastric tube (0 d vs.4 d,P ＜0.001),and shorter passing flatus time [(1.6 ± 0.8) d vs.(2.9 ± 1.4) d,P =0.006] than the CRAS group;however,no difference was found in terms of intraoperative colliod infusion [(1 110.0 ± 331.5)ml vs.(1 117.9 ± 397.9) ml,P =0.954].No patients from either group required conversion to open surgery.There was no significant difference between the two groups for operative time (P =0.311),estimated blood loss (P =0.073),drain days (P =0.681),postoperative hospital stay (P =0.509),overall blood transfusion (P =1.000),intensive care unit stay (P =1.000) and tumor characteristics (pathological stage,histology,nodes removed,positive nodes,lymph node-positive patients,positive surgical margins).The 30-day postoperative complications were documented in 5 (50％)and 23 (59％)patients in groups ERAS and CRAS (P =0.878),respectively.And the most common complication were minor complications (Clavien-Dindo grade 1 and 2) in both groups (100.0％ vs.86.9％,P =0.729).The 30-day readmission rate was 20.0％ (2 patients) in ERAS group and 10.3％ (4 patients) in CRAS group with no statistical significance(P =0.588).Conclusions Our ERAS protocol expedited bowel function recovery after RC and urinary diversion without increasing in 30-day complications compared with CRAS.The key of implement ERAS pathway is to explore and develop their own protocol conformed to their medical treatment enviroment.
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Objective To summarize the characteristics of IgG4 related disease (IgG4-RD),and to avoid unnecessary surgical procedures due to misdiagnosis.Methods Retrospective analysis of the clinical data of one case of IgG4 related disease involving the renal pelvis in our hospital,and the clinical features of IgG4 related disease involving the renal pelvis were reviewed and discussed.A 56-year-old man presented with microscopic hematuria,CT showed right renal pelvis and ureteral wall thickening,local soft tissue density,post contrast CT showed low-density renal pelvic mass and the wall of the ureter-pelvic was irregularly thicken,indicating renal pelvic cancer and lymph node metastasis.PET-CT (18F-FDG) findings indicated that the renal pelvic mass was a malignant tumor,because the glucose metabolism was very high.The preoperative diagnosis was retroperitoneal lesion,suspecting renal pelvic carcinoma or lymphoma.The patient underwent 3D laparoscopic nephroureterectomy with out preoperative biopsy.During operation,we found extensive enlargement of the right renal portal and retroperitoneal lymph nodes,including that the renal portal and the renal pelvis mass had a serious adhesion to the vena cava and renal arterial vein.Results Postoperative pathology results revealed lymphatic tissue hyperplasia and germinal center formation.Immunohistochemical staining showed that most plasma cells positive expression of IgG4 (IgG4 ＞ 40％,IgG4 ＞ 100/HPF),reactive hyperplasia of lymph node,considering the IgG4 related diseases.Serum IgG4 level was 15.2 g/L (0.03-2.01 g/L)after operation.Combined with serological examination,IgG4 related disease was confirmed.There was no evidence of IgG4-related disease at any other site during the follow up period,thereby obviating the need for any additional therapy.Conclusions IgG4 related disease is a novel clinical disease entity characterized by elevated serum IgG4 concentration and tumefaction or tissue infiltration by IgG4-positive plasma cells,which leads to the enlargement of the organ or nodular/proliferative lesions.The disease can be revealed as a soft tissue tumor of the renal pelvis and be misdiagnosed as malignant tumor.Surgical intervention could be avoided according to the correct diagnosis.
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Objective To investigate the expression of insulin-like growth factor Ⅱ mRNA binding protein 3 (IMP3) in non-muscle invasive bladder cancer and its relationship with the tumor recurrence and progression.Methods IMP3 protein expression was detected by immunohistochemistry in 130 cases of nonmuscle invasive bladder cancer specimens who underwent transurethral resection the first time at Beijing Chao-Yang hospital,from October 2010 to October 2013.Besides,we analyzed 20 cases of muscle-invasive samples and 20 benign tissues adjacent to cancer as control.The 130 patients were followed up by telephone and other methods.According to the UICC-TNM standard.Survival analysis was calculated by using the Kaplan-Meier method,and the difference in survival curves was analyzed by using the log-rank test.For multiple analyses,The Cox proportional hazards regression model was used.Results The positive expression rate of IMP3 in 130 patients with non-muscle invasive bladder cancer was 59.2％ (77/130),of which 30.0％ (39/130) was weak expression,29.2％ (38/130) was strong.However there was 80.0％ (16/20) in muscle-invasive specimens,of which 20.0％ (4/20) was weak,60.0％ (12/20) was strong (P =0.011).IMP3 was not detected in all benign tissues adjacent to cancer (P ＜0.001).All the 130 patients were followed-up for 5 to 69 mnonths,45 cases experienced disease recurrence,20 patients had progressed and 12 cases died.IMP3 expression was significantly related to higher tumor stage (P ＜ 0.001),high tumor grade (P =0.014),and tumor recurrence (P =0.003).Kaplan-Meier plots and log-rank tests showed that patients with IMP3-positive tumors had a lower disease-free survival (P =0.002) and progression-free survival rate (P =0.010) than those with IMP3-negative tumors.In the multivariable Cox analysis,we found that IMP3 protein was an independent predictor of disease-free survival (P =0.010) in non-muscle invasive urothelial carcinoma of bladder.Conclusions IMP3 was not expressed in benign tissue adjacent to cancer,whereas highly expressed in bladder cancer,and high IMP3 expression is an independent prognostic factor in NMIBC that can identify the patients with a high potential to relapse.
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Objective To investigate the difference of surgical efficacy between extended lymph node dissection and standard lymph node dissection in laparoscopic radical cystectomy.Methods We retrospectively analyzed 62 bladder cancer cases,icluding 52 males and 10 females patients in our hospital from January 2011 to October 2016,who underwent laparoscopic radical cystectomy and pelvic lymph node dissection.Their mean age was (62.5 ± 9.6) years,ranged from 42 to 83 years.27 cases were underwent extended lymph node dissection and 35 cases were underwent standard lymph node dissection respectively.The basic characters,operative time,intraoperative blood loss,intraoperative and postoperative complications,postoperative eating time,postoperative activity time,postoperative hospital stay,lymph nodes positive rate,lymph node density,and cancer-free survival were evaluated.Results All patients were underwent successful operation.There was no significant difference in operation time [(326.2 ± 77.5) min vs.(345.5 ± 66.8) min,P =0.297],blood loss [(198.2 ± 77.5) ml vs.(213.7 ± 160.0) ml,P =0.590],intraoperative complications (0/27 vs.5/35,F =0.063),postoperative complications (8/27 and 9/35,P =0.732),postoperative eating time[(4.8 ±2.2)d vs.(4.6 ± 1.9)d,P =0.817],postoperative activity time[(1.9 ± 0.8) d vs.(1.9 ± 0.9) d,P =0.838] and postoperative hospital stay[(15.6 ± 7.5) d vs.(16.0 ± 5.9)d,P =0.483].In this study,994 lymph nodes and 100 positive lymph nodes were dissected.There were significant differences in the number of lymph nodes dissected in the two groups (23.2 ±6.6 vs.10.5 ±3.6,P ＜0.01).40.74％ (11/27) of cases in ePLND were lymph node positive and the lymph node density was 11.7％ (73/626),which was higher than that of the sPLND group (28.57％ vs.7.34％,respectively).In regard to prognosis,the cancer-free survival rate (DFS) of ePLND group was 96％,91％,80％ and 71％ at 3,6,12 and 24 months follow-up respectively.The other group was 97％ 94％,84％,80％ correspondingly.And no significant difference was detected (P =0.546).Although there was no significant difference (P ＞ 0.05),DFS of ePLND group tended to be higher than that of sPLND group in lymph node positive subgroups.Conclusions Extended lymph node dissection and standard lymph node dissection have similar surgical safety and prognosis,and appropriate surgical procedures should be selected according to the patient's condition.
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Objective To evaluate the effect of micropercutaneous nephrolithotomy(microperc) for treatment of renal calculi with self-made F 4.8 optic puncture needle combined with ureteral access sheath.Methods There were 23 patients undergoing microperc with the self-made device from June 2016 to April 2017,Male,12 cases,female,11 cases.The mean ±SD (range) patient age was (49 ±14) years(28-67 years),stone volume was (1.7 ± 0.6) cm (1.0-3.0 cm) and stone density was (934.5 ± 282.7) HU (357-1 500 HU).The self-made all-seeing system consists of a puncture needle (F4.85) and two 3-way connector allowing the insertion of a flexible microoptic system,laser fiber and attaching to irrigation system.Single tract with one puncture with ultrasound guide was fit to treat the calices containing calculi or calices at one stage operation.The course of puncture could be " all-see" on the display which was connected with flexible microoptic system.After stone fragmentation,the procedure was terminated in tubeless fashion.Ureteral double J stent was inserted in order to prevent postoperative complications.The factors analysed were demographic variables including age,sex,stone volume,stone density [Hounsfield units (HU)] and stone location,and intra-and peri-operative variables such as operating time,drop in haemoglobin level,stone clearance and complications.Results Conversion to PCNL was required in one patient because intraoperative bleeding obscured vision.The mean ± SD (range) operation duration was (46.2 ± 19.9) min (20-120 min),pain score was 2.8 ± 1.2(1-6),hemoglobin decrease was 6.6 g/L,and in hospital time was (2.9 ± 0.8) d (2-5 d),respectively.No patient required blood transfusion.Stone-free rate at 1 and 3 months postoperation was 90.9％ (20/22) and 100 ％ (22/22),respectively.Two who suffered hematuria (Clavien Ⅰ)underwent conservative treatment and recorered well.One suffered urinary tract infections (Clavien Ⅱ) and was treated with antibiotics.There were no major complications.Conclusions Mircoperc with the self-made device and ureteral access sheath in management of renal calculi is feasible and effective.