Three dimensional nephrometry system for partial nephrectomy: Our initial exploration / 北京大学学报(医学版)

OBJECTIVE@#To construct a preoperative evaluation system for partial nephrectomy using CT three-dimensional visualization technology and to explore its practical value.@*METHODS@#The clinical data of the patients who underwent partial nephrectomy for renal tumors in Department of Urology, Peking University First Hospital were collected retrospectively. At the same time, the homogenized standard data of patients who underwent partial nephrectomy for renal tumors were collected in 16 clinical centers in China. The CT three-dimensional visualization system was applied (IPS system, Yorktal) to evaluate tumor anatomy, blood supply, perirenal fat and other information. The parameters were summarized to build a three-dimensional nephrometry system, on the basis of which virtual surgery design and intraoperative navigation were completed.@*RESULTS@#A three-dimensional visualization image was established based on the enhanced CT urography. The nephrometry system included the longest diameter and volume of the tumor, proportion volume of tumor invading the parenchyma, maximum depth of the tumor invading the parenchyma, contact surface area, flatness of the tumor surface, renal segment where the tumor was located, vascular variation, and perirenal fat. The average two-dimensional diameter of the tumor was (2.78±1.43) cm, the average three-dimensional maximum diameter was (3.09±1.35) cm, and the average postoperative pathological size was (3.01±1.38) cm. The maximum tumor diameter in the three-dimensional image was significantly related to the prolonged renal artery clamping time and intra-operative blood loss (r=0.502, P=0.020; r=0.403, P=0.046). The three-dimensional and pathological tumor volume were (25.7±48.4) cm3 and (33.0±36.4) cm3, respectively (P=0.229). The tumor volume was significantly related to the intraoperative blood loss (r=0.660, P < 0.001). The proportion volume of the tumor invading into renal parenchyma was significantly related to the prolongation of renal artery clamping and the occurrence of postoperative complications (r=0.410, P=0.041; r=0.587, P=0.005). The tumor contact surface area and the presence of vascular variation did not show correlation with the perioperative data and postoperative complications. While the preoperative evaluation was completed, the reconstructed three-dimensional image could be zoomed, rotated, combined display, color adjustment, transparency, and simulated cutting on the Touch Viewer system. The process generally consisted of showing or hiding the tissue, adjusting the transparency of the interested area, rotating and zooming the image to match the position of the surgical patient. Together, these functions met the requirements of preoperative virtual surgery plan and intraoperative auxiliary navigation.@*CONCLUSION@#Three-dimensional images can provide a more intuitive anatomical structure. The CT three-dimensional visua-lization system clearly displays tumor anatomical parameters, blood supply and perirenal fat. The three-dimensional nephrometry system for renal tumors can help predict the difficulty of partial nephrectomy and perioperative complications. Importing the reconstructed three-dimensional visualization image into the specified program or robot operating system can complete virtual surgery and intraoperative navigation, helping the surgeon to better grasp the surgical process. The indexes included in the nephrometry system and the score weights of each index need to be confirmed and perfected by multi-center study with large samples.

Robot-assisted laparoscopic upper urinary tract reconstruction surgery: A review of 108 cases by a single surgeon / 北京大学学报(医学版)

OBJECTIVE@#To summarize the experiences and outcomes of 108 robot-assisted laparoscopic upper urinary tract reconstruction surgeries conducted by a single surgeon.@*METHODS@#We consecutively and retrospectively reviewed 108 patients who underwent robot-assisted laparoscopic upper urinary tract reconstruction surgeries by a single surgeon from November 2018 to January 2020. The patient demographics, perioperative variables, postoperative complications and follow-up data were recorded. Fifty-three modified dismembered pyeloplasties (MDP), 11 spiral flap pyeloplasties (SFP), 11 ure-teroureterostomies (UUT), 4 lingual mucosal onlay graft ureteroplasties (LMU), 5 appendiceal onlay flap ureteroplasties (AU), 11 ureteral reimplantations (UR), 6 Boari flap-Psoas hitch surgeries (BPS) and 7 ileal ureter replacements (IUR) were enrolled finally. The success was defined as the improvement in subjective pain levels, and the improvement in the degree of hydronephrosis at ultrasound.@*RESULTS@#All the surgeries were successfully completed without open or laparoscopic conversion. The median operative time was 141 min (range: 74-368 min), median blood loss was 20 mL (range: 10-350 mL) and median hospital stay was 4 d (range: 3-19 d) in MDP group, with the success rate of 94.3%. The median operative time was 159 min (range: 110-222 min), median blood loss was 50 mL (range: 20-150 mL) and median hospital stay was 5 d (range: 3-8 d) in SFP group, with the success rate of 100%. The median operative time was 126 min (range: 76-160 d), median blood loss was 20 mL (range: 10-50 mL) and median hospital stay was 5 d (range: 4-9 d) in UUT group, with the success rate of 100%. The median operative time was 204 min (range: 154-250 min), median blood loss was 30 mL (range: 10-100 mL) and median hospital stay was 6 d (range: 4-7 d) in LMU group, with the success rate of 100%. The median operative time was 164 min (range: 135-211 min), median blood loss was 75 mL (range: 50-200 mL) and median hospital stay was 8.5 d (range: 6-12 d) in AU group, with the success rate of 100%. The median operative time was 149 min (range: 100-218 min), median blood loss was 20 mL (range: 10-50 mL) and median hospital stay was 7 d (range: 5-10 d) in UR group, with the success rate of 90.9%. The median operative time was 166 min (range: 137-205 min), median blood loss was 45 mL (range: 20-100 mL) and median hospital stay was 5 d (range: 4-41 d) in BPS group, with the success rate of 83.3%. The median operative time was 270 min (range: 227-335 min), median blood loss was 100 mL (range: 10-100 mL) and median hospital stay was 7 d (range: 5-26 d) in IUR group, with the success rate of 85.7%.@*CONCLUSIONS@#The surgeon performed and modified numerous complicated upper urinary tract reconstruction surgeries by the robotic platform, which facilitated the development of the standardized upper urinary tract reconstruction surgical technique.

Application of preoperative three-dimensional image reconstruction in the treatment of ureteropelvic junction obstruction / 北京大学学报(医学版)

OBJECTIVE@#To investigate the value of preoperative three-dimensional image reconstruction in the treatment of ureteropelvic junction obstruction (UPJO).@*METHODS@#We reviewed data on 40 patients (22 male cases, and 18 female cases) diagnosed with UPJO in Peking University First Hospital from May 2017 to April 2019. The median age was 26.5 years (IQR 23.25-38.75) years. There were 11 patients complicated with ectopic vessels, 14 patients with kidney stones, 3 patients with horseshoe kidney, and 6 patients with obstruction after pyeloplasty. All the patients underwent preoperative enhanced CT scan, and the CT data were reconstructed into three-dimensional image models. The obstruction position of ureteropelvic junction and the relationship between ureteropelvic junction and blood vessels and organs were observed by three-dimensional models to assist planning surgery. Thirty-seven patients underwent laparoscopic pyeloplasty (including 3 cases combined with pyelolithotomy with flexible cystoscope, 1 case combined with pyelolithotomy by sun-style cystoscope, 1 case with laparoscopic ureter resection and anastomosis, 3 cases of laparoscopic pyeloplasty of horseshoe kidney), 2 patients underwent laparoscopic ventral onlay lingual mucosal graft ureteroplasty, and 1 patient underwent robot-assisted laparoscopic pyeloplasty.@*RESULTS@#Three-dimensional CT image clearly showed the relationship between the obstruction of ureteropelvic junction and blood vessels and organs after three-dimensional reconstruction. The type, diameter, position and direction of the ectopic vessels could be observed clearly before operation according to the three-dimensional reconstruction model, and the number, size, location and shape of renal calculi or other masses, the number of involved renal calyces and the anatomical distribution in the renal pelvis and calyces could be also evaluated preoperatively. After comprehensive analysis of the above information, individualized operation plans were performed on the patients, all the 40 cases were successfully completed with the surgery without any transfer to open surgery. The average operative time was (129.91±37.90) min (range: 75 to 273), the average blood loss was (48.1±78.0) mL (range: 10 to 400), the average hospitality was (5.04±1.99) d (range: 2 to 10), and the average postoperative drainage time was (3.8±1.4) d (range: 2 to 8).@*CONCLUSION@#The preoperative three-dimensional image reconstruction has a high clinical value in the treatment of ureteropelvic junction obstruction, and it is of great help to assist surgery planning and is worthy of further clinical promotion and application.

Advances in surgical repair of ureteral injury / 北京大学学报(医学版)

Ureteral injury can be classified as iatrogenic or traumatic, which represents a rare but challenging field of reconstructive urology. Due to their close proximity to vital abdominal and pelvic organs, the ureters are highly susceptible to iatrogenic injury, while ureteral injury caused by external trauma is relatively rare. The signs of ureteric injury are difficult to identify initially and often present after a delay. The treatment of ureteral injury, which is depended on the type, location, and degree of injury, the time of diagnosis and the patient's overall clinical condition, ranges from simple endoscopic management to complex surgical reconstruction. And long defect of the ureter presents much greater challenges to urologists. Ureterotomy under endoscopy using laser or cold-knife is available for the treatment of 2-3 cm benign ureteral injuries or strictures. Pyeloplasty is an effective treatment for ureteropelvic junction obstruction and some improved methods showed the possibility of repairing long-segment (10-15 cm) stenosis. Proximal and mid-ureteral injuries or strictures of 2-3 cm long can often be managed by primary ureteroureterostomy. When not feasible due to ureteral defects of longer segment, mobilization of the kidney should be considered, and transureteroureterostomy is alternative if the proximal ureter is of sufficient length. And autotransplantation or nephrectomy is regarded as the last resorts. Most of the injuries or strictures are observed in the distal ureter, below the pelvic brim, and are usually treated with ureteroneocystostomy. A non-refluxing technique together with a ureteral nipple or submucosal tunnel method, is preferable as it minimizes vesico-ureteral reflux and the risk of infection. In order to cover a longer distance, ureteroneocystostomy in combination with a psoas hitch (covering 6-10 cm of defect) or a Boari flap (covering 12-15 cm) is often adopted. Among various ureteral replacement procedures, only intestinal ureteral substitution, which includes ileal ureter, appendiceal interposition and reconfigured colon substitution, has gained wide acceptance when urothelial tissue is insufficient. Ileal ureter can be used to replace the ureter of >15 cm defect and even to replace the entire unbilateral ureter or bilateral ureter. Laparoscopic and robotic-assisted techniques are increasingly being employed for ureteral reconstruction and adopted with encouraging results.

Application of totally extraperitoneal renal autotransplantation with Boari flap-pelvis anastomosis in upper urinary tract urothelial carcinomas treatment / 北京大学学报(医学版)

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.@*METHODS@#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.

Review of upper urinary modified minimal invasive surgical technology / 北京大学学报(医学版)

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.

Effect of forchlorfenuron on fruit morphology and lignans content of Schisandra chinensis / 中国中药杂志

The effect of plant growth regulator forchlorfenuron (CPPU) 1 x 10(-6), 0.67 x 10(-6), 0.5 x 10(-6) on fruit morphology and effective components lignans was studied. Those morphologies were the combination of four basic morphological changes. The result showed, diametre were increased and longitudinal diametre of fruits were inhibited by foliage fertilizers including CPPU. At the same time, 1 000-grain weight and yield showed the varying degrees increase under CPPU. The order of the degree was 0.5 x 10(-6) > 1 x 10(-6) > 0.67 x 10(-6). Six lignans content of Schisandra chinensis of different harvest time and different CPPU processing groups were determined, the results showed that lignans accumulation occurred mainly in periods of premature the half mature fruiting stages. Under the 0.67 x 10(-6) CPPU treatment, schisandrol B, schisandrin B, schisandrin C content of S. chinensis showed different increase.

Identification of Schisandra chinensis with white fruits based on ITS2 sequences / 中国中药杂志

<p><b>OBJECTIVE</b>To analyse a special kind of Schisandra chinensis with the white fruit using ITS2 barcode at molecular levels.</p><p><b>METHOD</b>ITS2 regions were sequenced bidirectionally. Sequence assembly and consensus sequence generation were performed using the CodonCode Aligner, MEGA 5.0 software was used to align the sequences. The ITS2 secondary structure was predicted using ITS2 web server, BLAST 1 method was used to identify the S. chinensis with the white fruit.</p><p><b>RESULT</b>The length of the ITS2 sequence was 231 bp. And the sample was identified as S. chinensis using the method of BLAST 1. Their mean interspecific genetic distance (K2P distance) among the populations of the S. chinensis with the white fruit and S. chinensis was far lower than the mean interspecific genetic distance between the S. chinensis and S. sphenanthera.</p><p><b>CONCLUSION</b>By using ITS2 the S. chinensis with the white fruit was identified as S. chinensis, and the ITS2 barcode could be used to identify S. chinensis and S. sphenanthera.</p>

HPLC determination of six lignans in different parts of Schisandra chinensis / 中国中药杂志

<p><b>OBJECTIVE</b>To compare the content of six lignans of different parts of Schisandra chinensis.</p><p><b>METHOD</b>Agilent TC-C18 (4.6 mm x 250 mm, 5 microm) was used with acetonitrile-water gradient system as mobile phase. Wave length was 250 nm. The flow rate was 1 mL x min(-1). Column temperature was 30 degrees C.</p><p><b>RESULT</b>The total lignans content of wild Schisandra chinensis was higher than that of the cultivated varieties. The total lignans content of different parts varied significantly, wherein the root > main branch > side branches > leaf.</p><p><b>CONCLUSION</b>This method is stable, reliable, can be used for the quality evaluation of different parts of Schisandra.</p>