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Objective:To investigate the treatment efficacy of adjuvant anti-VEGF/VEGFR targeted therapy in patients with non-metastatic (cM 0) non-clear cell renal cell carcinoma and tumor thrombus (nccRCC-VTT). Methods:This retrospective study enrolled 26 patients who underwent radical nephrectomy combined with inferior vena cava tumor thrombectomy at Peking University Third Hospital from January 2014 to July 2021. Patients were divided into adjuvant therapy group (10 cases) and control group (16 cases)based on the use of postoperative targeted therapy. The distribution of baseline clinical characteristics in the adjuvant therapy group and the control group were as follows: gender (6 males and 4 females in the adjuvant therapy group, 12 males and 4 females in the control group, P=0.66), age (56.2±18.5 years old in the adjuvant therapy group; 54.6±14.5 years old in the control group; P=0.80), BMI(24.0±3.5 in the adjuvant therapy group; 24.3±3.3 in the control group; P=0.80), presence of clinical symptoms (8 cases in the adjuvant therapy group; 15 cases in the control group; P=0.54), tumor laterality(6 cases on the left and 4 cases on the right in the adjuvant therapy group; 6 cases on the left and 10 cases on the right in the control group; P=0.42), location of tumor thrombus (2 cases with renal vein tumor thrombus and 8 cases with inferior vena cava tumor thrombus in the adjuvant therapy group; 2 cases with renal vein tumor thrombus and 14 cases with inferior vena cava tumor thrombus in the control group; P=0.67), ASA classification (2 cases in ASA class 1 and 8 cases in ASA class 2 in the adjuvant therapy group; 2 cases in ASA class 1 and 14 cases in ASA class 2 in the control group; P=0.63), surgical approach (7 minimally invasive surgeries and 3 open surgeries in the adjuvant therapy group; 9 minimally invasive surgeries and 7 open surgeries in the control group; P=0.68), conversion to open surgery (2 cases in the adjuvant therapy group; 2 cases in the control group; P=0.63), operation time [287.5(222.2, 456.0) minutes in the adjuvant therapy group; 344.0(287.8, 482.5) minutes in the control group; P=0.34), blood loss [400.0(250.0, 600.0)ml in the adjuvant therapy group; 575.0(175.0, 800.0)ml in the control group; P=0.63), Clavien-Dindo classification of postoperative complications (8 cases with no postoperative complications, 2 cases with level 1-2 complications, and 0 cases with level ≥3 complications in the adjuvant therapy group; 10 cases with no postoperative complications, 4 cases with level 1-2 complications, and 2 cases with level ≥3 complications in the control group; P=0.68), postoperative hospital stay (8.5 [5.5, 11.5] days in the adjuvant therapy group; 7.5 [6.0, 13.0] days in the control group; P=1.00), maximum tumor diameter[ (9.2±2.7)cm in the adjuvant therapy group; (8.9±3.3)cm in the control group; P=0.81], sarcomatoid differentiation (0 cases in the adjuvant therapy group; 1 case in the control group; P=1.00), perinephric fat invasion (2 cases in the adjuvant therapy group; 7 cases in the control group; P=0.40), tumor necrosis (6 cases in the adjuvant therapy group; 5 cases in the control group; P=0.23), pathological subtype (1 case of PRCC type 1, 6 cases of PRCC type 2, and 3 cases of TFE3 rearrangement RCC in the adjuvant therapy group; 2 cases of PRCC type 1, 10 cases of PRCC type 2, and 1 case each of oncocytic PRCC, TFE3 rearrangement RCC, FH-deficient RCC, and unclassified RCC in the control group; P=0.72), WHO/ISUP nuclear grade (10 cases of grades 3-4 in the adjuvant therapy group; 4 cases of grades 1-2 and 12 cases of grades 3-4 in the control group; P=0.14), invasion of tumor thrombus into the vessel wall (5 cases in the adjuvant therapy group; 5 cases in the control group; P=0.43), T stage (1 case of T 3a, 3 cases of T 3b, 5 cases of T 3c, and 1 case of T 4 in the adjuvant therapy group; 1 case of T 3a, 4 cases of T 3b, 10 cases of T 3c, and 1 case of T 4 in the control group; P=1.00), and positive lymph nodes metastasis(3 cases in the adjuvant therapy group; 0 cases in the control group; P<0.05). The recommended doses for sunitinib, axitinib, and pazopanib are 50mg qd, 5mg q12h, and 800mg qd, respectively. The primary endpoint of this study was disease-free survival (DFS), and the secondary endpoint was overall survival (OS). Statistical analyses were performed using R v4.2.2. Confounding factors were adjusted using propensity score weighting. Results:The median follow-up time for DFS was 29 months in the adjuvant therapy group and not reached in the control group, while median follow-up time for OS was 28 and 26 months, respectively. In the univariate Cox regression analysis, there were no statistically significant difference in the impact of all baseline characteristics and exposure factors on DFS and OS between the two groups. In survival analysis, there were no significant difference between DFS and OS curves of patients in the adjuvant therapy group and the control group (DFS, P=0.62; OS, P=0.74). The median DFS of patients in the adjuvant therapy group and the control group were 17 and 19 months, respectively, while the median OS was 43 and 27 months. After adjusting for confounding factors, the median DFS of patients in the adjuvant therapy group and the control group were 26 and 12 months, respectively, and the median OS remained 43 and 27 months, with no significant difference (DFS, P=0.81; OS, P=0.40). Conclusion:There is currently a lack of definitive evidence for survival benefit from adjuvant anti-VEGF/VEGFR targeted therapy in patients with cM0 nccRCC-VTT after surgery.
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Objective:To Explore the diagnosis, treatment and prognosis of FH-deficient renal cell carcinoma (FH-deficient RCC) with tumor thrombus, and share surgical experience.Methods:From August 2019 to October 2022, 6 cases of FH-deficient RCC with tumor thrombus were diagnosed and treated in our center, including 4 males and 2 females. The patients were aged 22 to 57 years, with 2 cases younger than 40 years, icluding 5 cases on the left and 1 case on the right. The median maximum diameter of the tumor is 8 (4.8, 14.0) cm. Operations were performed after complete examination (enhanced CT and other related examinations). One case underwent open surgery and palliative resection of the left kidney was performed because of severe adhesion of the inferior vena cava. Among the remaining 5 cases, 1 case underwent retroperitoneal laparoscopic right radical nephrectomy with inferior vena cava thrombectomy, 1 case underwent transabdominal laparoscopic left radical nephrectomy with inferior vena cava thrombectomy, and 3 cases underwent robot assisted laparoscopic left radical nephrectomy with inferior vena cava thrombectomy.Results:The median surgical time was 293 (185, 366) min, with blockage of the vena cava for 13 min and 28 min in 2 of 6 cases, respectively. The pathological report of renal tumor and tumor thrombus was FH-deficient renal carcinoma. The pathological features were as follows: the gross section of the specimen was gray yellow solid, often accompanied by necrosis, and the cystic cavity could be seen locally. Microscopically, the tumor extensively involved the renal parenchyma, with papillary, cribriform and tubular cystic structures. Immunohistochemistry showed FH (-), 2SC (+ ). The median postoperative hospital stay was 8 (4, 15) days. The median follow-up time was 13 (4, 27) months. One patient undergoing palliative resection of the left kidney underwent targeted therapy and radiotherapy after surgery (died 15 months after surgery due to gastrointestinal perforation). During the follow-up process, 4 cases experienced metastasis and received systematic treatment, with 1 death 27 months after surgery. Uterine leiomyomas were found in the remaining 1 case during follow-up.Conclusions:FH-deficient RCC with tumor thrombus is very rare. This disease is highly invasive, difficult to be diagnosed preoperatively and poor clinically prognostic. Operation combined with systemic therapy is an effective way to treat FH-deficient RCC with tumor thrombus.
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Objective:To assess whether urinary incontinence after holmium laser enucleation of the prostate (HoLEP) is associated with membranous urethral length(MUL)on preoperative magnetic resonance imaging.Methods:The data of 96 patients who underwent HoLEP from January 2019 to April 2021 in Peking University Third Hospital were retrospectively analyzed. For all patients, the average age was (70.0±7.7) years old, the average body mass index was (23.9±2.9)kg/m 2, median pre-biopsy PSA was 3.79(2.48, 6.03)ng/ml, the average prostatic volume was (60.5±35.0)ml. 22 patients(22.9%) suffered with diabetes mellitus, and 17 patients(17.7%)had at least one time urinary retention. MUL was measured on MRI as the vertical distance from prostatic apex to the entry of the urethra into the penile bulb. All patients' median MUL was 13(11, 17)mm. The recovery of continence was followed up 2 weeks after HoLEP. The difference of age, body mass index, preoperative PSA, diabetes mellitus, urinary retention, prostate volume and MUL between urinary continence and incontinence group 2 weeks after HoLEP operation. The variables with P<0.1 were included in multivariable logistic regression to analyze the independent risk factors of urinary incontinence after HoLEP were compared. Results:All operations were successfully completed. The continence returned to normal in 72 cases (75.0%) and urinary incontinence existed in 24 cases (25.0%) in 2 weeks after surgery. There were 27 cases (37.5%) in continence group and 16 cases (66.7%) in incontinence group for those aged≥70 years. 21 cases (29.2%) in continence group and 13 cases (54.2%) in incontinence group had prostate volume ≥ 60 ml. There were 30 cases (41.7%) in continence group and 20 cases (83.3%) in incontinence group with MUL<13 mm. χ 2 test showed that age ( P=0.013), prostate volume ( P=0.027) and MUL ( P<0.001) were related to the incontinence after surgery. The age, prostate volume and MUL were included in the multivariate logistic regression analysis. Multiple logistic regression showed that MUL<13 mm( P<0.001) was independent predictor for incontinence after HoLEP. Conclusions:The incidence of urinary incontinence was high 2 weeks after HoLEP. Short MUL, which is less than 13 mm, is significantly associated with delayed recovery of urinary continence after HoLEP.
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Objective:To summarize the surgical technique and clinical experience of robotic-assisted laparoscopic radical nephrectomy (RN) + venous tumor thrombectomy (VTTE) approach for renal tumor with Mayo grade 0-Ⅲ tumor thrombus, and to discuss its safety and efficacy.Methods:A retrospective analysis of the clinical data of 26 patients with renal tumor associated with Mayo 0-Ⅲ thrombus admitted to Peking University Third Hospital from October 2020 to September 2021. There were 17 male cases and 9 female cases. The mean age was (56.9±13.9) years. The mean body mass index (BMI) was (25.8±3.5) kg/m 2. The renal tumors were located on the left side in 12 cases and on the right side in 14 cases, with a mean tumor diameter of (7.8±2.9) cm. The tumors were graded by Mayo: Mayo 0 in 10 cases, Mayo Ⅰ in 3 cases, Mayo Ⅱ in 11 cases and Mayo Ⅲ in 2 cases. The American Society of Anesthesiology (ASA) graded 23 cases as grade 2 and 3 cases as grade 3. All 26 patients were treated by robotic-assisted laparoscopic approach with RN+ VTTE. Mayo 0 tumor thrombus was treated in the same way as radical nephrectomy. For Mayo Ⅰ tumor thrombus, the lateral wall of the IVC at the inferior vena cava (IVC) where the renal vein joins was clamped to partially block the IVC flow and then the thrombus was removed. For Mayo Ⅱ tumor thrombus, after blocking the flow in the IVC with three blocking bands, the wall of the IVC was dissected and the thrombus was removed. For Mayo Ⅲ tumor thrombus: cut the short hepatic vein, free the liver, expose the posterior IVC and follow the same procedure as for Mayo Ⅱ tumor thrombus. Results:All 26 patients in this group were successfully operated on, 1 of which was converted to open surgery. The median operative time was 148.5 (77.0-399.0) min, and the median intraoperative estimated bleeding volume was 300 (10-2000) ml. Postoperative pathological diagnosis: 18 cases of renal clear cell carcinoma, 2 cases of papillary renal cell carcinoma type Ⅱ, 2 cases of TEF gene fusion-related renal carcinoma, 1 case of unclassified renal cell carcinoma, 1 case of uroepithelial carcinoma and 2 cases of AML. In 2 of the 26 cases, segmental resection of the IVC was performed because the right renal VTT had extensively invaded the wall of the IVC. Due to the residual wall thrombus at the head of the tumour thrombus, 1 case underwent inferior vena cava dissection and the inferior vena cava was cut obliquely to preserve the left renal venous return. 6 patients underwent intraoperative lymph node dissection of the hilum, three of which had pathology suggestive of lymph node metastasis. 1 patient underwent adrenalectomy for tumor invasion of the ipsilateral adrenal gland. The median postoperative hospital stay was 7.2(4.0-22.0)d. According to the modified Clavien classification, there were 18 grade Ⅰ and 8 grade Ⅱ postoperative complications. 26 patients were followed up for 1-11 months, with a median follow-up time of 5.5 months. 3 cases developed distant metastases, including 1 case with tumour-specific death due to multiple metastases in the liver and retroperitoneum at 4 months of follow-up.Conclusions:Robotic-assisted laparoscopic RN+ VTTE is a safe and effective procedure for the treatment of renal tumours with Mayo 0 to Ⅲ tumour thrombus, with the advantages of delicate operation, minimal trauma and low incidence of serious postoperative complications.
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It is unclear whether antidepressants have the same effects on the brain function at different periods of treatment.In this paper, in order to improve the understanding of the neurobiological mechanisms of antidepressants from brain network level, find the target of antidepressants, optimize treatment strategy, four common neuroimaging techniques were reviewed to investigate the changes of brain functional imaging in patients with major depressive disorder at different periods (short-term, acute and long-term) after antidepressant treatment.After short-term antidepressant treatment, the changes of brain functional imaging mainly involved the amygdala, insula, prefrontal cortex, dorsal anterior cingulate cortex and so on, and these short-term changes of brain functional imaging could predict acute efficiency.After acute stage of antidepressant treatment, the changes of brain functional imaging were mostly located in the brain regions of cortical-limbic circuit and default mode network.The effect of long-term antidepressant treatment on brain functional imaging still needs to be further studied.In the future, the experimental design should be optimized and multiple neuroimaging techniques should be combined to conduct longitudinal long-term studies at multiple time points.
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Introducing the multidisciplinary cooperation model into the clinical teaching of residents has gradually been paid attention to, and the relevant multi-disciplinary teaching teams participate in and formulate teaching plan. The Department of Urology of the Peking University Third Hospital carries out multidisciplinary cooperative teaching of residents based on network platform to improve residents' autonomous learning ability and teaching effect. This model has certain advantages in mobilizing students' subjective initiative and cultivating learning interest. It is of great significance for the training of urology residents.
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Objective:To investigate the effect of different imaging classifications of prostate cancer seminal vesicle invasion on positive surgical margins (PSM) after laparoscopic radical prostatectomy(LRP).Methods:114 patients with pT 3b stage prostate cancer admitted to Peking University Third Hospital from August 2009 to December 2020 were retrospectively analyzed. The age of the patients was (68.2±7.7) years old, the median pre-biopsy PSA was 20.20 (3.45-186.30) ng/ml, and the patients with biopsy Gleason score of ≤7, and ≥8 was 33 and 81 cases, respectively. The median prostate volume was 33.2 (12.1-155.4) ml. According to the imaging of the seminal vesicle invasion of prostate cancer, the patients were divided into the following types: type Ⅰ, the tumor directly invades the seminal vesicle along the vas deferens; type Ⅱa, the tumor invades the basal capsule of the prostate and invades the seminal vesicle; type Ⅱb, the tumor invades the periprostatic fat and retrogradely invades the seminal vesicles; type Ⅲ, solitary lesions in the seminal vesicles that do not continue with the prostate cancer. All patients underwent LRP, and the PSM were recorded as the base, bilateral, posterior, anterior and apical parts of the prostate. The differences in clinicopathological data of patients with different seminal vesicle invasion imaging types were compared, and the independent risk factors of PSM in pT 3b prostate cancer were evaluated by multivariate analysis. Results:The operative time of 114 cases in this group was (229.4±62.2) min, and the blood loss was 100(20-1 800)ml. The postoperative gross pathological Gleason score was ≤7 in 17 cases and ≥8 in 97 cases. In the imaging classification of prostate cancer with seminal vesicle invasion, there were 28 cases (24.6%) of type Ⅰ, 39 cases (34.2%) of type Ⅱa, 47 cases (41.2%) of type Ⅱb, and no type Ⅲ patients. There was no significant difference in age, body mass index, pre-biopsy PSA, prostate volume, and operation time among patients with type Ⅰ, Ⅱa, and Ⅱb seminal vesicle invasion ( P>0.05). There was a statistically significant difference in blood loss among the three types ( P = 0.001), and the difference in the proportion of lymph node metastasis was statistically significant ( P = 0.013). In the classification of prostate cancer seminal vesicle invasion, the PSM rates of type Ⅰ, Ⅱa and Ⅱb were 28.6% (8/28), 38.5% (15/39) and 70.2% (33/39), and the difference was statistically significant ( P=0.001). The PSM rates of type Ⅰ, Ⅱa, and Ⅱb were 21.4% (6/28), 23.1% (9/39), and 34.0% (16/47), respectively. The results of univariate analysis showed that the biopsy Gleason score ( P = 0.063) and the type of seminal vesicle invasion ( P<0.001) entered into multivariate analysis, and the results of multivariate logistic regression analysis showed that the type of seminal vesicle invasion ( P=0.001) was independent risk factor for PSM after LRP. Conclusions:The PSM rate in patients with type Ⅱb seminal vesicle invasion is significantly higher. The higher imaging type of seminal vesicle invasion is the independent risk factor of PSM after LRP.
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Preservation of erectile function is an important goal of radical prostatectomy. The neurovascular bundles (NVBs), which is closely related to erectile function, are quite susceptible to intraoperative injury because it is difficult to be identified and localized during surgical process. As a result, long-term postoperative potency rate is not satisfying. Techniques of monitoring pro-erectile neurovascular bundles, such as electrical stimulation, ultrasound and MRI have significant limitations in the context of real-time identification during operation. Advances of fluorescence imaging in the surgical navigation field has made it possible to achieve real-time visualization of NVBs in vivo. At present, there have already been many fluorescent agents worldwide targeting different structures within nerves, such as the axon, myelin, perineurium and vaso nervorum, and they varied in their affinity to nerves and imaging efficacies. Some lipophilic molecules, oxazine dyes and peptide-dye conjugates have successfully visualized in periprostatic autonomic nerves in rodents or in human prostate specimen. Indocyanine Green (ICG), a non-specific neurovascular dye, has already been used in clinical setting to guide during nerve-sparing radical prostatectomy. This review focused on fluorescent nerve imaging technique and its application in research on real-time imaging of NVBs in radical prostatectomy.
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Objective:To identify the relationship between positive surgical margin after laparoscopic radical prostatectomy and intravesical prostatic protrusion length on preoperative magnetic resonance imaging.Methods:We retrospectively analyzed 110 patients with pathologic confirmed prostate carcinoma who underwent laparoscopic radical prostatectomy in our hospital. For all 110 patients, the average age was (70.4±7.8) years old, median pre-biopsy PSA was 12.23 ng/ml(range 0.78-110 ng/ml). There were 27 cases, 35 cases and 48 cases for biopsy Gleason score 6, 7 and ≥8. There were 73 patients with clinical stage T 1 and T 2, 37 patients with clinical stage T 3.The median prostatic volume was 38.16ml(range 11.83-163.36ml). MRI examination was performed in 1 week before the biopsy. Intravesical prostatic protrusion length (IPPL) was measured on MRI as the vertical distance from the tip of the protruding prostate to the base of the urinary bladder. All patients who underwent MRI preoperatively median IPPL was 3 mm(range 0-27 mm). There were 72 patients with IPPL<5 mm and 38 patients with IPPL≥5 mm respectively. All patients received extra-peritoneal laparoscopic radical prostatectomy. Parameters describing the surgical margin status and the location of positive surgical margin was recorded. The χ 2 tested the statistical significance in proportions differences. The multivariable logistic regression was used to assess risk factors for positive surgical margin and positive base surgical margin(PBSM). Results:Positive surgical margin rate was 38.1% for all patients, 25 patients(22.7%) had PBSM.χ 2 test showed that clinical stage ( P<0.001) and IPPL ( P=0.038) were related to the postoperative positive surgical margin. The clinical stage, Gleason score and IPPL were included in the multivariate logistic regression analysis. Multiple logistic regression showed that T 3 stage( P<0.001) was independent predictor for positive surgical margin. χ 2 test showed that clinical stage( P<0.001) and IPPL( P=0.001) were related to the postoperative PBSM. The clinical stage, Gleason score and IPPL were included in the multivariate logistic regression analysis. T 3 stage( P<0.001)and IPPL≥5 mm ( P=0.009) were independent predictors for PBSM according to multivariable logistic regression. Conclusions:For prostate cancer patients who received laparoscopic radical prostatectomy, clinical stage T 3was an independent risk factor for postoperative positive surgical margin. IPPL≥5 mm on preoperative magnetic resonance imaging and clinical stage T 3 were independent risk factors for PBSM.
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Objective:To explore the value of preoperative aspartate transaminase(AST) and aspartate transaminase/alanine transaminase ratio(AST/ALT)for predicting the prognosis in patients with non-metastatic renal cell carcinoma with tumor thrombus.Methods:A retrospective analysis was made of the patients with renal cell carcinoma with tumor thrombus in our institution from February 2015 to December 2018. This study included 80 patients, 56 males and 24 females with mean age of 58 years (range 15-83 years). There were 17 in Mayo level 0, 24 Mayo level I, 22 in Mayo level II, 12 in Mayo level III and 5 in Mayo level IV. All the patients received radical nephrectomy or palliative nephrectomy with tumor thrombectomy. The continuous variable of AST/ALT was collected by ROC curve. The maximum value of Youden index was taken as the critical value, and the continuous variables were adjusted to binary variables. Cancer-specific survival (CSS) was calculated according to the Kaplan-Meier analysis and compared by the log-rank test. Cox multivariate regression analysis was used to analyze the independent factors of the prognosis of patients with non-metastatic renal cancer and tumor thrombus.Results:There were 70 cases of clear cell carcinoma, 10 cases of non-clear cell carcinoma, 30 cases of low Fuhrman grade (grade 1&2), and 50 cases of high Fuhrman grade (grade 3&4). AST was 19U/L (8-226 U/L) and AST/ALT was 1.3(0.4-3.3). There was a significant difference in AST between different lymphovascular invasion groups ( P=0.04), but there was no significant difference in sex, age, Mayo classification, pathological type, Fuhrman grade and lymph node metastasis. The difference of AST / ALT between age groups was significant ( P=0.025). The average follow-up time was 14.7 months (0-44 months). During the follow-up, 11 (13.8%) patients died of tumor. Univariate analysis showed that Fuhrman grade ( P=0.007), lymph node metastasis ( P=0.019), hemoglobin ( P=0.001), alkaline phosphatase (ALP, P=0.001), AST ( P=0.004) and AST / ALT ( P=0.038) were risk factors for CSS. In terms of prognosis, considering the potential correlation between AST level and AST/ALT ratio, after excluding AST, multivariate Cox regression analysis showed that high nuclear grade ( HR=3.049, 95% CI 1.292-7.196, P=0.011), high ALP ( HR=1.018, 95% CI 1.007-1.029, P=0.001) and high AST/ALT ratio ( HR=4.094, 95% CI 1.064-15.759, P=0.04) were associated with poor CSS. After excluding AST/ALT ratio, multivariate Cox regression analysis showed that high nuclear grade ( HR=5.836, 95% CI 1.867-18.240, P=0.002) and high AST ( HR=1.040, 95% CI 1.017-1.062, P<0.001) were associated with poor CSS. Conclusions:In patients with non-metastatic renal cell carcinoma with tumor thrombus, high AST/ALT ratio and AST levels indicate poor pathological types and poor prognosis.
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Objective:To investigate the safety and effectiveness of cytoreductive nephrectomy and tumor thrombectomy in patients with metastatic renal cancer with renal vein or inferior vena cava tumor thrombus.Methods:From February 2015 to May 2019, 56 cases of metastatic renal cell carcinoma with venous tumor thrombus were analyzed retrospectively, including 44 male (78.6%) and 12 female (21.4%)cases, and the average age was (59.2±10.7)(22-82). The clinical presentations covered local symptoms in 26 cases (46.4%), systemic symptoms in 8 cases (14.3%), both local symptoms and systemic symptoms in 12 cases (21.4%), and asymptomatic in 10 cases (17.9%). Among them, renal tumors were located in 35 cases (62.5%) on the right and 21 cases (37.5%) on the left. The average tumor diameter was (10.1±3.8)(1.5-21.1) cm. Forty-five cases (80.4%) scored 2 points and 11 cases (19.6%) scored 3 points by the American Society of anesthesiologists(ASA). Preoperative hemoglobin was (118.2±23.1)(72-178) g/L, and albumin was (37.9±5.6)(23-50) g/L, total protein was (67.7±6.7)(43-81) g/L, serum creatinine was (111.3±119.6)(32-958) μmol/L. There were 16 cases of Mayo 0 (28.6%), 14 cases of Mayo Ⅰ(25.0%), 17 cases of Mayo Ⅱ(30.4%), 4 cases of Mayo Ⅲ(7.1%), and 5 cases of Mayo Ⅳ(8.9%). Fourteen cases (25.0%) were in the stage of cN 0 and 42 cases (75.0%) in the stage of cN 1. Five cases (8.9%) had simple bone metastasis, 16 cases (28.6%) had simple lung metastasis, 2 cases (3.6%) had simple adrenal metastasis, 6 cases (10.7%) had simple liver metastasis, and 27 cases (48.2%) had 2 or more multiple system metastasis. According to the location of the organ system, 91 metastatic lesions were found in 56 patients. Among them, 37 cases (40.7%) had lung metastasis, 18 cases (19.8%) had liver metastasis, 21 cases (23.1%) had bone metastasis and 15 cases (16.5%) had adrenal metastasis. All 56 patients belonged to IMDC prognosis score model medium risk group. The surgical treatment of Mayo grade 0 tumor thrombus was the same as that of routine radical nephrectomy. The tumor thrombus of Mayo grade Ⅰ was removed after IVC was partially blocked by Satinsky′s forceps. The Mayo Ⅱ tumor thrombus was removed, after blocking the distal vena cava, the contralateral renal vein and the proximal vena cava. Mayo grade Ⅲ tumor thrombus needed pringer's method to block the first porta hepatis. For grade Ⅳ tumor thrombus the diaphragm could be cut directly, or the thrombus could be removed by cardiopulmonary bypass. Laparoscopic surgery was performed in 22 cases (39.3%) and open surgery in 30 cases (53.6%). Six cases (10.7%) underwent IVC wall resection because of tumor invasion. 32 cases (57.1%) underwent ipsilateral adrenalectomy because of tumor invasion or adrenal metastasis, and 23 cases (41.1%) underwent ipsilateral lymphadenectomy. In this study, there were 11 cases of solitary metastasis, 8 cases of which were operated on and 3 cases of which were not operated on. Forty-three patients were treated with sunitinib after palliative nephrectomy, 9 patients were treated with pazopanib, 3 patients were treated with acitinib, and 1 patient was treated with sorafenib. Results:The operations were successfully completed in 56 patients. Four cases (7.1%) changed from laparoscopic surgery to open surgery. The operation time was (326.8±114.9)(108-589) min. Intraoperative hemorrhage was (1 435.2±1 513.4)(20-6 000) ml, intraoperative red blood cells transfusion was (1 456.7±832.8)(400-3 600) ml in 30 cases, and intraoperative plasma transfusion was (700.0±473.6)(200-1 800) ml in 15 cases. The postoperative hospital stay was (10.6±4.6)(5-26) days. The serum creatinine one week after operation was (109.5±98.7) (47-772) μmol/L. There were 46 cases (82.1%) of renal clear cell carcinoma, 7 cases (12.5%) of papillary renal cell carcinoma and 3 cases (5.4%) of unclassified renal cell carcinoma. One case was WHO/ISUP 2016 nuclear grade 1 (1.8%), 20 cases(36.4%) was grade 2, 18 cases(32.7%)was grade 3, and 16 cases(29.1%)was grade 4. Early postoperative complications occurred in 22 cases (39.3%). Among them, 1 case of Clavien gradeⅠ was wound infection. There were 16 cases with Clavien gradeⅡ, including 5 cases who received blood transfusion due to anemia, 3 cases with chylous fistula, 4 cases with postoperative pulmonary infection, 2 cases with postoperative lower extremity venous thrombosis, 1 case with atrial fibrillation and 1 case with epididymitis. Clavien gradeⅢ a was found in 1 case with pneumothorax. Clavien gradeⅣ was found in 2 cases, including 1 case of acute cerebral infarction and 1 case of renal insufficiency.There were 2 cases with Clavien gradeⅤ with perioperative death. Among the 56 patients, 5 lost the follow-up, 2 died during the perioperative period, and the other 49 patients were followed up for 1-39 months, with a median follow-up of 14 months. The mean survival time was (25.6±2.5) months, and the median survival time was 25 months.Conclusions:It was relatively safe and effective to perform cytoreductive nephrectomy and tumor thrombectomy in patients with metastatic renal cancer with tumor thrombus. For the patients with clinical symptoms, IMDC prognosis score model medium risk group, and strong desire for surgery, the combination of cytoreductive nephrectomy with tumor thrombectomy and postoperative targeted medical therapy was recommended.
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The prognosis of metastatic renal cell carcinoma is relatively poor. With the development of molecular biology, the treatment of metastatic renal cell carcinoma is undergoing a transformation from cytokine therapy to targeted molecular therapy or immunotherapy, and the prognosis has been improved. This study summarized and discussed the treatment progress of metastatic renal cell carcinoma.
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Objective:To analyze the prognostic factors of primary and metastatic tumor resection for metastatic renal carcinoma.Methods:Clinical data of 12 cases of renal carcinoma with distant metastasis admitted to the Peking University Third Hospital from June 2011 to December 2019 were analyzed retrospectively, including 10 males and 2 females. Age was from 36 to 67 years old, with average of 53.7 years old. BMI was 20.9-30.8 kg/m 2, with average of 25.8 kg/m 2.There were 6 cases of right kidney tumor and 6 cases of left kidney tumor. The diameter of the primary tumor was 2.7-16.0 cm, with an average of 7.1 cm. There were 2 cases of lung metastasis, 1 case of liver metastasis and 9 cases of bone metastasis. All the 12 patients underwent primary and metastatic tumorectomy. Postoperative pathological results showed 10 cases of clear cell carcinoma, 1 case of papillary type 2 tumor and 1 case of collecting duct carcinoma. The pathological results of the metastases were the same as those of the original lesions. Results:All the 12 patients underwent primary and metastatic renal carcinoma resection, among which 3 received postoperative chemotherapy and 6 received radiotherapy .Two patients were treated with targeted drugs. The interval between primary resection and metastatic resection was 1-84 months, and the median time was 2.5 months. In this study, 12 patients were followed up for 2-96 months, with the median survival time of 34 months, and mortality rate of 25%.There was no significant correlation between age( P=0.265), gender( P=0.183), BMI( P=0.152), primary tumor size ( P=0.082), radiotherapy, chemotherapy or targeted therapy ( P=0.915) and overall survival, and the interval between primary resection and metastatic resection ( P=0.046) was significantly correlated with overall survival. Conclusion:The interval between primary and metastatic tumor resection was a risk factor for the prognosis of patients.
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Objective To investigate the causes and preventive measures for deviation of guide needle in orthopedics robot surgery.Methods A robotic surgery was simulated on a wooden stick.The guide needle was inserted under the guidance of the robot.A lateral deviation force was applied respectively onto the tail and tip of the needle.The actual offset distance at the guide needle tip was measured and compared with the 1mm offset allowed by robot monitoring.Results The offset distance of the guide needle tip was 0,5+0.07 mm when the deviation force was applied onto the tail,significantly smaller than the 1 mm offset allowed by the robot monitoring(l=22.588,P<0.001).The offset distance of the guide needle tip was 4.92+0.16 mm when the deviation force was applied onto the tip,significantly larger than the 1 mm offset allowed by the robot monitoring(t=17.416,P<0.001).Conclusions The deviation of guide needle may be caused chiefly by the deviation force onto the tip.As the actual offset distance of the guide needle tip may be larger than that shown on the robot monitor in orthopedics robotic surgery,the intraoperative monitoring should serve only as a reference to the deviation of the guide needle.The operative details may be the key to prevention of such deviations.
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Objective@#To evaluate the effects of orthopedic robot navigation system used in core decompression combined with bone graft surgery for osteonecrosis of the femoral head (ONFH).@*Methods@#A retrospective analysis was performed on 9 patients (16 hips) underwent core decompression surgery combined with bone graft treatment for early ONFH in ARCO Ⅱat Department of Osteoarthropathy, Yantaishan Hospital from June 2016 to February 2018.There were 7 males and 2 females, aged 44.6 years (range: 28-60 years). All surgery procedures were completed by the same doctor under the navigation of orthopedic surgery robot using the specific designed tools. The preoperative and postoperative Harris Hip Score and visual analogue score were compared and the time of intraoperative X-ray fluoroscopy was recorded.@*Results@#The mean follow-up period was (12.7±3.5)months (range: 6-18 months). Four cases of treatment failure were observed in 16 hips at the last follow-up and the hip survival rate was 12/16.In stage ARCO Ⅱa, Ⅱb and Ⅱc, the survival rate was 1/1, 2/2, and 9/13.The Harris Hip Score (88.3±1.9 vs.70.0±3.8, t=16.81, P=0.000) and visual analogue score (3.7±0.7 vs. 0.9±0.6, t=13.49, P=0.000) were improved significantly at the last follow-up compared with preoperative value. The total times of intraoperative X-ray fluoroscopy were 15.9±2.5, including 5.8±1.2 before the insertion of the guiding wire and 10.1±1.7 after the insertion of the guiding wire.@*Conclusions@#The domestic orthopedic surgery robot can be applied successfully in the core decompression combined with bone graft surgery for ONFH . It is less invasive with less fluoroscopy time and better bone graft effects.
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How to cultivate professional degree postgraduates with independent and innovative research ability has become an important goal of graduate education.In this article,doctoral postgraduates in the department of urology were chosen as subjects who received education of English book report and received education of new style of literature review in different time.In order to explore the effective measures to cultivate the clinical scientific research quality and ability of the professional degree postgraduates in Department of Urology,we evaluated different kinds of research quality of postgraduates under different methods of literature review through the scores of teachers' judges and questionnaires.
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Objective To investigate the diagnosis and treatment of ipsilateral multiple renal malignant tumors.Methods 4 patients with multiple renal malignant tumors were retrospectively reviewed from May 2013 to November 2017.All cases were males,with average age of 64 years old (ranging 54-82 years old).Two cases were found thai tumor located in right side.The duration of disease ranged from 7 days to 6 months,with an average of 2 months.One case was found the tumor due to the complaining of lumbar discomfort,and other 3 cases were found by physical examination.The number of tumors was 2 in 1 case,and 3 in 3 cases.The sonographic features of the tumors were iso-echoic nodules.CT showed irregular soft tissue shadow,partially prominent outside the kidney,and heterogeneous enhanced after enhancement.3 cases were undergone laparoscopic radical nephrectomy and 1 case which was solitary kidney,was undergone laparoseopic partial nephrectomy.Results All operations were performed successfully.3 cases were undergone laparoscopic radical nephrectomy,which the operative time was 189-271 min (average,230 min),and blood loss was 50-100 ml (mean 83 ml).Postoperative hospitalization time was 5-14 days,average 9.7 days.1 case occurred intestinal obstruction after surgery,which was improved after treatment.1 case was found the close distance of 3 tumors during the laparoscopic surgery.In order to short the ischemic duration,open surgery conversion was performed in this case.The total operation time was 207min.The ischemic time was 15min and blood loss was 50 ml.The postoperative hospital stay was 6 days.Pathological reported that 3 cases were clear cell carcinoma,another 1 case was clear cell carcinoma with papillary carcinoma.All patients were followed up for 2-55 months (mean 38 months).No recurrence sign was recorded in all cases.Conclusion Ipsilateral multiple renal malignant tumors are rare,laparoscopic radical nephrectomy is effectie.Meanwhile,partial nephrectomy can also be chosen in some optimal cases.
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Objective To investigate the safety and feasibility of operation to treat left renal carcinoma with Mayo Ⅱ tumor thrombus in double inferior vena cava.Methods The clinical data from a 52-year-old male suffered painless gross hematuria for 6 days and left back pain for 3 days was analyzed retrospectively.Enhanced CT examination of kidneys showed double inferior vena cava malformation.The confluence level of the left and the right inferior vena cava was at L1/2 disc level by a 80 degree angle.The left inferior pole of kidney showed an irregular soft tissue density,the size was 6.1 cm × 4.5 cm × 5.6 cm,considering the possibility of renal cancer.The tumor thrombus invaded into the inferior vena cava below the hepatic vein with a maximum diameter of about 3.2 cm.The top of the tumor thrombus was about 6.0 cm above the left renal vein.It showed a Mayo Ⅱ] tumor thrombus.Preoperative diagnosis was left renal carcinoma with Mayo Ⅱ tumor thrombus in double inferior vena cava.The patient underwent radical nephrectomy under general anesthesia.We separated hepatic inferior vena cava,right renal vein,right inferior vena cava,left inferior vena cava and left renal vein.Sequential occlusion was completed of left inferior vena cava,right inferior vena cava,right renal vein,hepatic inferior vena cava.Vascular wall of inferior vena cava was cut open and the tumor thrombus was removed at the level of inferior vena cava bifurcation.During the operation,the wall of left inferior vena cava was invaded by tumor thrombus.So all the left kidney,the left renal vein,the left inferior vena cava invaded by tumor thrombus were resected.We sutured the vena cava incision continuously.Sequential occlusions were removed of right renal vein,right inferior vena cava,hepatic inferior vena cava.We clamped the vessel wall of right inferior vena cava by auricle clamp and made an incision longitudinally.Then we made an end to side anastomosis of the left and right inferior vena cava.Results The surgical procedure was successful and the postoperative recovery was favorable.The operation time was 442 min.And blood loss was 3 000 ml.The postoperative pathology result showed that the tumor was clear cell renal cell carcinoma,2016 WHO/ISUP grade was Ⅱ] to Ⅲ.There was no metastasis of left renal hilum lymph node,abdominal aorta and vena cava lymph node.There was no metastasis of adrenal gland.The abdominal cavity drainage tube and the urinary catheter was removed 7 days postoperatively.He was discharged from hospital 8 days postoperatively.There were no obvious postoperative complications.The patient was followed up for 3 months and there was no tumor recurrence or metastasis.Conclusions Our initial clinical result show that radical nephrectomy,Mayo]Ⅱ venous thrombectomy,left and right inferior vena cava end to side anastomosis is safe and effective.But the operation is difficult and complex.
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Objective To investigate the effect of pelvic position angle on the angle of acetabular prosthesis by computer navigation system.Methods Computer navigation technique was used to simulate total hip arthroplasty (THA) on the whole pelvis.The anteversion and abduction angle of acetabular prosthesis were measured when the pelvis rotated around horizontal axis,long axis and sagittal axis.Results With the increase of the angle of the pelvis on the horizontal axis,the angle of the acetabular prosthesis was linearly decreased (Y=-1.32X+1,r=-0.982,P＜0.001) and the abduction angle showed a linear increase (Y=0.398X+ 3,r=0.975,P＜0.001).The obliquity and abduction angle of the acetabular component increased linearly angle (Y=0.764X+2,r=0.998,P＜0.001;Y=0.394X+4,r=0.975,P＜0.001) with the increase of the backward inclination.With the increase of the rotation angle of the pelvis to the left in the long axis,the anteversion angle of the acetabular component increased linearly (Y=l.42X+21,r=0.985,P＜0.001),and the abduction angle decreased linearly (Y=-0.67X+3,r=-0.976,P＜0.001).With the increase of the fight rotation angle of the pelvis,the anteversion and abduction angle of the acetabular component showed a linear increasing trend (Y=0.75X+2,r=0.997,P＜0.001;Y=3.94X+4,r=0.990,P＜0.001).With the increase of the sagittal axial oblique angle of the pelvis,the antegrade angle of acetabular prosthesis increased linearly (Y=0.39X+ 19,r=-0.993,P＜0.001),and the abduction angle decreased linearly (Y=-0.75X+7,r=-0.964,P＜0.001).The antegrade angle of acetabular prosthesis decreased linearly (Y=-0.11X+ 11,r=-0.990,P＜0.001) with the increase of the fight tilt angle of the pelvis,while the abduction angle increased linearly (Y=0.92X+4,r=0.994,P＜0.001).Conclusion The change of pelvic position angle has great influence on the angle of acetabular prosthesis placement,suggesting that the different pelvic position is very important during operation.Computer navigation can reduce the influence of pelvic position angle on the angle of acetabular prosthesis placement.
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Objective To investigate the safety and feasibility of radical nephrectomy and Mayo 0-Ⅳ venous thrombectomy.Methods The clinical data of 52 patients with Mayo 0-Ⅳ tumor thrombus from February 2015 to January 2017 were analyzed retrospectively.Of the 52 patients,42 were male and 10 were female.The average age was (59.8 ± 13.6) years old (2.5 to 84.0 years).The renal vein tumor thrombus or inferior vena cava tumor thrombus was found in all patients,including type 0 thrombus in 12 cases,type Ⅰ thrombus in 11 cases,type Ⅱ thrombus in 15 cases,type Ⅲ thrombus in 9 cases,type Ⅳ thrombus in 5 cases (Mayo Medical Center classification).Imaging suggested the right renal tumor in 36 cases and left tumor in 16 cases.The average tumor size was (8.5 ±2.0) cm(2.0-21.1 cm).There were 2 cases of ASA Ⅰ,40 cases of ASA Ⅱ and 10 cases of ASA Ⅲ according to the American Society of Anesthesiologists (ASA).In laparoscopic radical nephrectomy and Mayo 0 venous thrombectomy,we clamped the vena cava vessel wall nearby the renal vein entrance.The vena cava blood flow was blocked partially.Then we cut the vessel wall arcuately.Mayo Ⅰ tumor thrombus requires the use of a non traumatic auricle clamp to control blood flow by the block of vena cava above thrombus,vena cava below the renal vein level,and the contralateral renal vein.Right kidney tumors with Mayo Ⅱ could be completed by retroperitoneal surgery.At the time of vascular occlusion,the distal inferior vena cava,the left renal vein and the proximal inferior vena cava were interrupted sequentially.For left renal tumors with Mayo Ⅱ,the retroperitoneal approach combined with transperitoneal approach was used.The technique of "milking" can shrink the tumor thrombus and reduced the difficulty of the operation.For Mayo Ⅲ tumor thrombus just at the hepatic vein level,we cut off 3-5 hepatic short veins,and separated inferior vena cava long enough to provide surgical field.For Mayo Ⅲ tumor thrombus much higher than the hepatic vein level,we used open surgeries to free the liver and porta hepatis.We first blocked the distal inferior vena cava,followed by the left renal vein,the hepatic artery and portal vein,at last the proximal inferior vena cava.Mayo Ⅳ tumor thrombus often required a median incision to open the chest and establish an extracorporeal circulation.Results All the 52 surgeries were completed successfully without intraoperative and perioperative mortality.Open radical nephrectomy and inferior vena cava thrombectomy was underwent in 22 cases.Pure laparoscopic surgery was under went in 30 case.Two cases were converted to open surgery.The average surgery time was(333.7 ±80.1)min(136-694 min).The average blood loss volume was (1339.0 ± 508.1) ml(20-10 000ml).During the operation,the amount of suspended red blood cells transfusion was(761.5 ± 394.8)ml(0-10 400ml).28 cases underwent regional lymph node dissection,and postoperative pathological diagnosis showed lymph metastasis in 4 cases.24 cases underwent ipsilateral adrenalectomy,and 2 cases showed tumor invasion of adrenal gland.7 cases with right tumors underwent inferior vena cava wall resection because of invasion by tumor thrombus.The average postoperative hospitalization of all 52 cases was (9.7 ± 4.7) d.Among 27 patients,early postoperative complications occurred in 18 cases (34.6％).There were 1 case of Clavien Ⅰ,12 cases of Clavien Ⅱ,1 case of Clavien Ⅲ a,2 cases of Clavien Ⅳ a and 2 cases of Clavien Ⅴ according to modified Clavien classifications.44 cases (84.6％) were followed up for 1 to 22 months with a median of 8 months.Postoperative recurrence occurred in 3 cases,and distant metastasis occurred in 9 cases.9 cases (20.5％) had tumor specific death.Conclusions Our initial clinical results show that radical nephrectomy and inferior vena cava thrombectomy is safe and effective for patients with Mayo 0-Ⅳ tumor thrombus,but the wide extension of vein tumor thrombus leads to the difficulty of operation technique.Sufficient preoperative preparation,rich operative experience and skills can improve the safety of operation.