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Bladder cancer is one of the most common tumors of the urinary system. More than a quarter of the new bladder cancer cases in China are muscle invasive bladder cancer. The standard treatment of muscle invasive bladder cancer is radical cystectomy plus pelvic lymph node dissection. This operation has limitations such as large trauma, high postoperative complication rate and serious impact on the quality of life of patients. To control the condition of bladder cancer and improve the quality of life of patients, a comprehensive treatment and follow-up system after bladder sparing are being explored. In addition to the classic trimodal treatment which is consisted of "maximum transurethral resection of the tumor, chemotherapy and external radiotherapy" , the treating modes of single drug, multi-drug or combined chemotherapy/radiotherapy based on immune checkpoint inhibitors are in their heyday. Meanwhile, antibody-drug conjugates have been in the ascendant. The purpose of this article is to review the current situation of bladder sparing therapy for muscle invasive bladder cancer and look forward to the development direction of bladder sparing therapy in the current era of oncoimmunology.
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Objective:To evaluate the clinical efficacy of transanal total mesorectal excision (taTME) on transanal endoscopic microsurgery (TEM) platform in the treatment of middle and low rectal cancer.Methods:The retrospective and descriptive study was conducted. The clinico-pathological data of 28 patients with middle and low rectal cancer who underwent taTME on TEM platform in the Peking Union Medical College Hospital of Chinese Academy of Medical Science from October 2014 to October 2017 were collected. There were 21 males and 7 females, aged 59 years (51 years, 68 years). Observation indicators: (1) surgical and postoperative situations; (2) follow-up. Follow-up was conducted using outpatient examination or telephone interview to detect post-operative defecation function and survival of patients up to October 2020. Patients underwent physical examination, examination of tumor markers including carcinoembryonic antigen and CA19-9, colonoscopy, rectal magnetic resonance imaging, thoracoabdominal and pelvic enhanced computed tomography (CT) and (or) PET-CT examination during the follow-up. Measurement data with normal distribution were represented as Mean±SD, and comparison between groups was analyzed using the independent sample t test. Measurement data with skewed distribution were represented as M( P25,P75) or M (range), and comparison between groups was analyzed using the non parameter Mann-Whitney U test. Count data were described as absolute numbers or percentages, and comparison between groups was analyzed using the chi-square test or Fisher exact probability. Results:(1) Surgical and postoperative situations: 28 patients underwent successful surgery, without intra-operative conversion to laparotomy. Of 28 patients, 24 cases underwent colorectal anastomosis and 4 cases underwent colon-anal anastomosis. Twenty-six cases underwent primary protective enterostomy and 2 cases didn't undergo primary protective enterostomy. The operation time of 28 patients was (182±37)minutes and the volume of intraoperative blood loss was 40mL(30 mL, 55 mL). One patient with intraoperative presacral hemorrhage received compression hemostasis. Eleven patients had postoperative complications, including 4 cases with anastomotic leakage, 2 cases with alteration of intestinal flora, 2 cases with paralytic ileus, 2 cases with urinary retention, 2 cases with urinary infection, 1 case with prolapse necrosis of small intestinal stoma, 1 case with anal hemorrhage, 1 case with rectovaginal fistula, 1 case with pelvic infection; some patients had multiple complications. Three patients had non-planned reoperation. One case without primary protective enterostomy had anastomotic leakage at postoperative 3 days, and was improved after emergency transversostomy. One case had prolapse necrosis of small intestinal stoma at postoperative 3 days and was improved after emergency enterostomy and reconstruction. One case with anal hemorrhage was stopped hemorrhage under anoscopy. Patients with other complications were cured after conservative treatments. The duration of postoperative hospital stay of 28 patients was 8 days(7 days, 9 days). Results of pathological examination in 28 patients showed 16 cases of moderately differentiated adenocarcinoma, 3 cases of moderately to highly differentiated adenocarcinoma, 5 cases of highly differentiated adenocarcinoma, 1 case of mucinous adenocarcinoma, 3 cases of pathological complete response. TNM staging of 28 patients showed 3 cases in stage T0N0, 4 cases in stage T1N0, 6 cases in stage T2N0, 4 cases in stage T2N1, 7 cases in stage T3N0, 3 cases in stage T3N1, 1 case in stage T4N1. The distance from tumor to distal margin was (2.2±1.7)cm. The surgical specimens of 28 patients showed negative for proximal, distal and circumferential margins. The number of lymph node dissection was 15±7. The complete rate of total mesorectal excision was 100%(28/28). Eleven of 28 patients underwent neoadjuvant therapy and 17 patients didn't receive neoadjuvant therapy. The tumor diameter, distance from tumor to anal margin, operation time, volume of intraoperative blood loss, duration of postoperative hospital stay were 2 cm(1 cm, 4 cm), 5 cm(4 cm, 6 cm), (187±25)minutes, 45 mL(38 mL, 53 mL), 8 days(7 days, 12 days) for patients with neoadjuvant therapy, respectively, versus 3 cm(2 cm, 4 cm), 5 cm(4 cm, 6 cm), (177±35)minutes, 40 mL(30 mL, 60 mL), 8 days(7 days, 8 days) for patients without neoadjuvant therapy, showing no significant difference between the two groups ( Z=-1.127, -0.293, t=0.590, Z=-0.790, -0.876, P>0.05). (2) Follow-up: 23 of 28 patients were followed up for (44±14)months. Of the 23 patients,11 cases were classified as grade A of Williams score for defecation function at postoperative 6 months, 8 cases were classified as grade B and 4 cases were classified as grade C. Eighteen of 23 patients with follow-up had disease-free survival, 1 of whom didn't undergo stoma closure due to anastomotic stenosis at postoperative 6 months. Three patients had distant metastasis, including 1 case with parastomal implantation metastasis, 1 case with sacral metastasis, 1 case with pulmonary metastasis. Two patients died, 1 case of whom died of urinary obstruction and 1 case with mucinous adenocarcinoma died at postoperative 24 months. Conclusion:TaTME based on TEM platform is feasible for middle and low rectal cancer, which has the advantages of preserving anus and negative circumferential margin.
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Objective@#To preliminarily explore the value of transanal endoscopic microsurgery (TEM) in rectal cancer patients with clinical complete response (cCR) following neoadjuvant chemoradiotherapy (nCRT).@*Methods@#Using descriptive case series method, Clinical data of 13 patients who met the criteria of nCRT and were considered to be cCR after MRI or CT scanning, digital rectal examination and colonoscopic biopsy, as well as no lymph node or distant metastasis were found, then underwent TEM from 2013 to 2016 at the Department of General Surgery of Peking Union Medical College Hospital were collected retrospectively. A 3-course combination of capecitabine and oxaliplatin (XELOX) was used for chemotherapy. Besides, a 6MV-X ray radiation was used as radiotherapy simultaneously. Six to eight weeks after completion of radiotherapy, a preoperative assessment was carried out with intrarectal ultrasound, MRI, or pelvic abdominal CT examination. TEM was performed afterwards with informed consent. Postoperative pathological findings and follow-up results were used to evaluate the value of diagnosis and treatment of TEM on those patients.@*Results@#There were 8 males and 5 females with a median age of 63 (27-80) years. Preoperative examination showed that the lesions were located in the anterior wall in 3 cases, the posterior wall in 3 cases, the left side wall in 4 cases, and the right side wall in 3 cases. Before nCRT, the distance between tumor and anal margin was (4.8±1.1) (2.0-7.5) cm; after nCRT, this distance was (5.2±1.3) (3.0-7.5) cm. All the 13 patients underwent extended local resection of rectal cancer via TEM with the placement of urethral catheter. The average operative time was (52.2±3.7) (42-70) minutes, and the average intraoperative blood loss was (19.2±2.8) (5-30) ml. All the patients could engage in daily activities on postoperative day 1, and could cater themselves orally on postoperative day 2. The main discomfort was postoperative anal pain and foreign body sensation (n=5), which could be alleviated by non-steroidal anti-inflammatory drugs. One case had postoperative lung infection and was cured by antibiotic treatment. One case had urinary retention after removing urine catheter, and then a urine catheter was re-inserted. Average postoperative hospital stay was (2.8±2.4) (2-12) days. All specimens were completely resected via TEM. Histopathological examination confirmed that 7 specimens had achieved pathologic complete response (pCR) and the other 6 specimens had obtained partial tumor response of CAP grade 2. Seven patients with pCR received a median follow-up of 24 (8-48) months and no local recurrence or distant metastasis was reported during follow-up period. Among these 7 cases, one developed defecation dysfunction after discharge, mainly for defecation pain and even dare to defecate, who returned to normal defecation within 2 months after surgery; One developed severe anal pain within six months after surgery and the pain disappeared after symptomatic pain relief. The other 6 patients with CAP grade 2 refused to undergo further radical operation because of their strong desire in preserving anus, and received remedial adjuvant chemotherapy instead.@*Conclusion@#For rectal cancer patients with cCR after nCRT, TEM does have certain application values if the patient has a strong desire to preserve anus.
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@#ObjectiveTo observe the effect of early rehabilitation on patients with closed traumatic brain injury (TBI).Methods80 TBI patients were divided into rehabilitation group and control group with 40 cases in each group. The control group was treated with routine surgical and other treatments. The rehabilitation group was treated with limb exercise and daily living training, besides treatments mentioned above. The scores of degrees of neural damage, Fugl-Meyer Assessment (FMA), modified Barthel index (MBI) and disability rating scale, and complications within 3 months of two groups were compared.ResultsThe scores of degree of neural damage, FMA, MBI and disability rating scale, and rate of complication of the rehabilitation group were significantly different from that of the control group (P<0.05～0.01).ConclusionEarly rehabilitation can improve brain function and reduce complication incidence of TBI patients.