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Objective:To investigate the safety and prognosis of partial nephrectomy (PN) in the treatment of highly malignant non-clear renal cell carcinoma (nccRCC).Methods:Clinical data of 47 patients with cT 1N 0M 0 high malignant nccRCC treated in Changhai Hospital from March 2016 to March 2022 were retrospectively analyzed. All patients received PN. There were 34(72.3%) males and 13(27.7%) females. The mean age was (53.5±15.0) years, and average BMI, was(23.7±3.4)kg/m 2.The maximum tumor diameter was (29.8±12.6) mm, and R. E.N.A.L. score was 7(5-9), with 37(78.7%) cases of T 1a and 10(21.3%) cases of T 1b. The mean estimated glomerular filtration rate (eGFR) before surgery was (96.3±25.5) ml/ (min·1.73m 2). All patients underwent PN, including 1 patient (2.1%) undergoing open surgery, 29 patients (61.7%) undergoing laparoscopic surgery, and 17 patients (36.2%) undergoing robotic surgery. There were a total of 22(46.8%) cases of papillary cell carcinoma(pRCC)type Ⅱ, 4(8.5%) cases of collecting duct carcinoma (cdRCC), 9(19.1%) cases of MiT family translocated renal cell carcinoma (tRCC), 5(10.6%) cases of mucoid tubular and spindle cell carcinoma (mtSCC)and 7(14.9%) cases of unclassified renal cell carcinoma (uRCC). The surgical conversion rate, positive margin rate, operative time, intraoperative blood loss, complications, and postoperative hospital stay were analyzed. Preoperative and postoperative eGFR were analyzed, and overall survival (OS) and cancer specific survival (CSS) were calculated. Results:All the operations were successfully completed. No radical operation or open operation was performed, with operation time of(100±60) min and intraoperative blood loss of(100±59) ml. There were no intraoperative complication and 1 case (2.1%) suffered from postoperative complication. Postoperative hospital stay were 5 (4-6) days. The mean eGFR after surgery was (86.5±27.1) ml/(min·1.73m 2), and the difference was statistically significant ( P=0.041). In this study, the mean follow-up time was (45.7±20.9)months, and no adjuvant therapy was used after surgery. During the follow-up period, 2 patients died, who all of them were kidney cancer-related death, and both OS and CSS were 95.7% (45/47). Conclusions:PN is safe, feasible and has a good prognosis in the treatment of high malignant T 1 nccRCC. For tumors with clear imaging boundaries and complete envelope, complete tumor resection is more likely, postoperative follow-up should be strict, and no remedial radical or systemic treatment was required.
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Objective:To explore the surgical technique and efficacy of pure retroperitoneoscopic extravesical standardized seeable (P.R.E.S.S.) technique for bladder cuff excision (BCE).Methods:Ninety five patients with UTUC from five domestic centers (30 cases from Changzheng Hospital, 21 cases from Peking University First Hospital, 20 cases from Yuhuangding Hospital, 21 cases from Dalian Medical University affiliated No.2 Hospital and 3 cases from General Hospital of Eastern Theater Command)between August 2017 and December 2020 were retrospectively analyzed. There were 57 males and 38 females with a mean age of (67.7±10.0) years and median tumor size of 3.0 cm. All patients underwent pure retroperitoneoscopic radical nephroureterectomy with a single surgical position and four (36 cases) or five (59 cases) trocar layout according to the surgeon’s prefer habit and experience. The demographics of the two groups were the age of [(66.3±11.2)years vs. (68.6±9.1)years], male/female ratio of (25/11 cases vs. 32/27 cases), body mass index of [(25.0± 3.0)kg/m 2 vs. (24.8±3.4)kg/m 2], tumor maximum diameter of [2.8(1.6, 3.5)cm vs. 3.0(2.0, 4.0)cm], left/right side tumor of(19/17 cases vs. 34/25 cases), T 1-2/T 3-4/Tis stage of(25/10/4 cases vs. 49/10/0 cases), and multifocal tumors of(3 cases vs. 2 cases), and the difference was not statistically significant( P>0.05). On the other hand, the differences of hydronephrosis of the operated kidney(13 cases vs. 39 cases, P=0.004), and tumor location (in renal pelvis or calyx or upper/middle/lower ureter being 23/9/4 cases vs. 35/4/20 cases, P=0.005), were statistically significant. The umbilical artery cord was used as anatomical landmark in the process of P. R.E.S.S. bladder cuff excision. The pelvic floor and extraperitoneal space around the ureter were expanded, the bladder wall was opened to form pneumovesicum, and a sufficient bladder cuff resection and exact bladder cuff closure was performed. Perioperative outcomes and follow-up data were analyzed, and the clinical outcomes between the four and five trocars were compared to evaluate the impact of trocar layout on the surgical outcomes. Results:There were 91(95.8%) cases successfully undergoing P. R.E.S.S. BCE technique, with one case converted to open BCE due to bleeding and three cases converted to distal ureter Hem-o-lok clipping because of poor exposure. Median operative time was 180(125, 230)min, and estimated blood loss was 100(50, 100)ml. The overall complication rate was 10.5%(10/95), including 2 cases(2.1%) of intraoperative bleeding, with 1 case treated by transfusion (400 ml), the other case converted to open surgery without transfusion. There were 8 cases of postoperative complications(8.4%), including 7 cases of Clavien-Dindo grade Ⅱ(3 cases of secondary hemorrhage, one case for each of drug allergy, acute renal insufficiency, blood creatinine increased to 490 μmol/L, or lung infection with lymphatic leakage), 1 case of grade Ⅲa(intestinal obstruction treated with insertion of the intestinal obstruction catheter under local anesthesia), and all these patients were discharged smoothly. The difference between the four and five trocars was not statistically significant in the following variables, including the rate of surgical conversion(8.3% vs. 1.7%), estimated intraoperative blood loss(100 ml vs. 60 ml), ratio of intraoperative lymph node dissection (25.0% vs.20.3%), P. R.E.S.S. bladder cuff excision success rate(91.7% vs.98.3%), the incidence of intraoperative and postoperative complications (13.8% vs.8.5%), pT 1-2/pT 3-4/pTis stage(22/11/3 cases vs.37/19/3 cases) and the proportion of recurrence or metastasis(8.3% vs.3.4%)(all P>0.05). However, the differences in the operation time(190 min vs.170 min, P=0.011)and postoperative hospital stay(5 d vs.6 d, P=0.005) were statistically significant. Conclusions:P. R.E.S.S. bladder cuff resection technique is safe and feasible during the procedure of pure retroperitoneoscopic radical nephroureterectomy by a single surgical position and facilitates seeable adequate bladder cuff excision by establishing an enlarged pelvic lateral extraperitoneal space and pneumovesicum. Five-trocar technique is more suitable for patients with lower ureteral tumors but may be associated with a longer postoperative hospital stay compared with the four-trocar technique.
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There are few reports on the study of extraperitoneal robotic single-port laparoscopic radical prostatectomy in China. In this study, patients with localized prostate cancer were treated with extraperitoneal robotic single-port laparoscopic radical prostatectomy extraperitoneal robot-assisted single-port laparoscopic radical prostatectomy(EpRA-spRP)from April 2019 to June 2019.All patients performed EpRA-spRP successfully without adding additional auxiliary port. The operation time and blood loss were controllable, and hospitalization time was short. It is safe and feasible to perform EpRA-spRP for medium and low-risk prostate cancer. The short-term tumor control and functional recovery are satisfactory.However, the long-term effect needs further follow-up and observation.
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Objective:To assess the safety and feasibility of single-port robotic radical cystectomy.Methods:During May 2019 and August 2019, nine patients (8 males, 1 female) received single-port robotic radical cystectomy by the same surgeon. The average age was 65.6(56-78)years. After a 4.5-5.5 cm trans-umbilical incision was made, Lagiport was inserted. Da Vinci Si system 1 #, 2 # arms and 30° lens were applied. Radical cystectomy and bilateral pelvic lymphadenectomy were performed without additional ports. Urinary diversion was completed outside the body. Uterus and vaginal anterior walls were also resected for female patient. Results:All 9 surgeries were successfully conducted without additional ports or conversion to laparoscopic and open surgery. The average operation time was 437.8(280-600)min. Urinary diversion methods included 2 orthotopic ileal neobladder, 5 ideal conduit and 2 cutaneous ureterostomy. Average estimated blood loss was 227.8(100-450)ml, without blood transfusion. Average intestinal recovery time was 3.1(2-4)days, drainage duration was 8.3(3-16) days, and postoperative hospital stays was 7.7(6-13) days. Pathological TNM stage: T 2aN 0M 0 6 cases, T 2bN 0M 0 1 case, T 3aN 3M 0 1 case, T isN 0M 0 1 case. All surgical margins were negative. One bowel obstruction was cured with fasting and indwelling gastric tube. During 9-12 months’ follow-up, no tumor recurrence and metastasis were observed. There was no hydronephrosis or ureterostenosis. All surgical incision healed well. Conclusions:For experienced surgeons, single-port robotic radical cystectomy is safe and feasible with small incision and fast recovery. Short-term clinical result is satisfied.
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Since the introduction of laparo-endoscopic single-site surgery(LESS) in China in 2008, this technique has developed rapidly in the domestic urology field. This paper systematically reviews and summarizes the historical process of the development of single-site laparoscopy technique in domestic urology. From the exploration period, the rapid development period, the rational thinking period to the current breakthrough development period, the technology has made great progress in related theoretical foundations, surgical operation skills, device development and clinical norms. It has many advantages such as less postoperative pain, minor damage in body surface, and rapid recovery. But the limitations including narrow operating space and great instrument interference are still remain. At present, the development of domestic single-site laparoscopy technique is generally stable and standardized. The robotic single-site surgery system may be able to effectively solve the problem of instrument interference, but the clinical advantages and application value of the robotic single-site surgery system still need to be further clarified by prospective, multi-center, large sample and high-quality clinical research.
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Objective:To investigate the factors related to the prognosis of patients with metastatic renal cell carcinoma after bone metastasectomy and to provide a reference for the clinical treatment of renal cell carcinoma.Methods:The clinical data of 143 patients with metastatic renal cell carcinoma in our center from January 2008 to December 2018 were retrospectively collected. Among 143 patients, 121 were male and 22 were female, with the average age of (54.8±12.5) year-old(from 18 to 85 year-old). The KPS scores of 138 patients were no higher than 80%. According to International Metastatic RCC Database Consortium (IMDC) risk model for metastatic renal cell carcinoma, the patients were divided into intermediate risk group (92 patients) and poor risk group (51 patients). The patients who had received complete resection for both primary lesion and metastatic tumor were regarded as tumor-free (47 patients). Otherwise, the patients with unresectable primary tumor or incomplete resection of the metastatic tumor were defined as the patients surviving conversely bone metastases were the only metastatic site, and the other 57 patients also experienced concomitant metastases comparatively. Sixty-two patients only had solitary bone metastasis lesion and 81 patients had multiple bone metastases. Kaplan-Meier survival analysis was used to calculate the 1-year, 3-year and 5-year survival rate. The impacts of different variables on the prognosis were examined by log-rank test. Univariate analysis and multivariable Cox proportional hazards regression models were used to identify the independent risk factors.Results:The median follow-up time was 49.0 months. The overall survival was 1-115 months, with the median OS was 24.0 months. The 1-year, 3-year and 5-year survival rate were 79.2%, 59.4% and 31.6%, respectively. All the patients underwent bone metastasectomy and 72 of them were treated with targeted therapy. The pathology results of metastasectomy were clear cell carcinoma for 132 patients and non-clear cell carcinoma for the 11 patients. In tumor-free group, the median OS was 30.0 months and in survival with tumor group, the median OS was 19.4 months, with a significant difference between the two groups ( P=0.030). In IMDC intermediate risk group, the prognosis was improved among the patients who received post-surgical targeted therapy after metastasectomy (24.3 months vs. 16.8 months, P=0.027), whereas the difference was not significant for IMDC poor risk group ( P=0.449). Age ≥60 years and multiple bone metastases sites were proved to be the independent risk factors for the prognosis of patients with metastatic renal cell carcinoma after bone metastasectomy. Conclusions:The prognosis of RCC patients with bone metastases was generally poor. Metastasectomy could prolong the OS of the patients who had undergone primary nephrectomy and had solitary bone metastasis. Metastasectomy combined with targeted therapy could significantly improve the prognosis of the IMDC intermediate risk patients. However, the effect of targeted therapy among IMDC poor risk patients remained to be further proved.
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Objective To compare the perioperative parameters and renal function in patients,whose aged was 65 year-old or above,with clinical T1-2 renal tumors undergoing partial nephrectomy (PN) or radical nephrectomy (RN).Methods A retrospective review of 469 patients,who underwent RN and PN in our center,was conducted from January 2012 to November 2018,icluding 247 in the RN group and 222 in the PN group.The RN group consisted of 170 male and 77 female patients,with the mean age of (70.96 ± 5.21) year-old.126 cases were found that the tumor located on the fight side,with the median diameter of (4.93 ± 2.03) cm.The median BMI,median R.E.N.A.L.score and pre-operation eGFR of the RN group were (24.4 ± 3.1) kg/m2,8.39 ± 1.45) and (80.23 ± 15.14) ml/(min · 1.73 m2),respectively.The PN group consisted of 150 male and 72 female patients,with the mean age of (70.23 ± 4.62) years old.108 patients had tumors on the left side while 114 on the right side,with the median diameter of (3.17 ± 1.41) cm.The median BMI,median R.E.N.A.L score and pre-operation eGFR of the PN group were (23.5 ± 3.2) kg/m2,(6.69 ± 1.81) and (82.83 ± 14.36) ml/(min · 1.73m2),respectively.No statistical difference was noticed in the age,gender,tumor location and BMI between RN group and PN group(P ＞ 0.05).The PN group had smaller tumors and lower R.E.N.A.L.scores than the RN group (P ＜ 0.05).Various parameters were compared between the PN and RN groups,including operative duration,surgical procedure,intraoperative blood loss,perioperative blood transfusion,drainage tube removal time,postoperative duration of hospitalization,pathological results,the renal function immediately after surgery and at 1 month,1 year,2 years,3 years,4 years,5 years after surgery,and the incidence of chronic renal dysfunction.Results Significant differences were found in multiple variables between the two cohorts,such as operative duration [(115.70 ± 39.69) min in RN vs.(132.26 ± 49.02) min in PN],estimated intraoperative blood loss [(45.85 ± 55.93) days in RN vs.(66.60 ± 61.55) ml in PN],drainage tube removal time [(4.38 ± 1.71) days in RN vs.(4.86 ± 1.61) days in PN],duration of postoperative hospitalization [(5.14 ± 1.65) days in RN vs.(5.52 ± 1.32) days in PN] (P ＜ 0.05).Furthermore,higher proportion of RCC was detected in the RN cohort (93.5％ in RN vs.86.5 ％ in PN,P ＜ 0.05).There was no significant difference in perioperative blood transfusion rate between the two cohorts (10.93％ vs.9.01％,P ＞ 0.05).Compared with the RN cohort,the PN cohort had higher eGFR immediately after surgery [(74.08 ± 18.31) ml/(min · 1.73m2) vs.(52.58 ± 14.21) ml/(min · 1.73m2)],1 month after surgery [(76.11 ± 18.34) ml/(min · 1.73m2) vs.(53.78 ± 15.03)ml/(min · 1.73m2)] and at the last follow-up [(73.92 ± 18.59) ml/(min · 1.73m2) vs.(52.35 ± 16.13) ml/(min · 1.73m2)] (P ＜ 0.001).Compared with those of the RN cohort,the incidences of eGFR ＜ 45 ml/(min · 1.73m2) of the PN cohort were lower immediately after surgery [9.01％ (20/222) vs.31.9％ (79/247)],1 month after surgery [7.87％ (14/178) vs.27.31％ (62/227)],1 year after surgery [8.96％ (13/145) vs.38.75％ (62/16 0)],2 years after surgery [9.89％ (9/91) vs.31.57％ (42/133)],3 years after surgery [13.21％ (7/53) vs.30.61％ (30/98)],4 years after surgery [16.21％ (6/37) vs.30.26％ (23/76)] and 5 years after surgery [18.18％ (4/22) vs.31.11％ (14/45)] (P ＜ 0.001).Conclusion The perioperative risk of PN in the treatment of elderly patients aged 65 and above with clinical cT1-2 renal tumor is controllable.PN could better retain renal function for those patients and reduce the risk of postoperative chronic renal insufficiency.
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Objective To compare the clinical outcomes of selective artery (SAC) with main artery (MAC) clamping of robotic partial nephrectomy (RPN) in patients with early-stage (cTiN0M0) renal masses.Methods Between October 2016 and September 2018,a total of 343 cT1 renal mass patients receiving RPN with SAC (n =21) or MAC (n =322) in our center,were retrospectively analyzed.There were 13 males and 8 females in SAC group with a mean age of (53.1 ± 10.6) years old,mean tumor size of (2.5 ±0.7)cm,and mean R.E.N.A.L.score of 6.2 ± 1.5.There were 149 males and 173 females in MAC group,with a mean age of (51.6 ± 12.3) years old,mean tumor size of(3.5 ± 1.4)cm,and mean R.E.N.A.L.score of 7.9 ± 1.6.There was statistical significance between two groups in tumor size and R.E.N.A.L score(P ＜ 0.001).The group covariates were balanced through propensity score matching (PSM) using 1:2 nearest neighbor matching method.After matching,mean age,tumor size,R.E.N.A.L.score and preoperative eGFR in the SAC and MAC groups were (3.1 ± 10.6) vs.(52.7 ± 10.2) years,(2.5 ± 0.7) vs.(2.6±0.7) cm,6.2 ±1.5 vs.6.2 ±0.9,and (101.7 ± 19.8)vs.(101.6 ±20.3) ml/(min · 1.73m2),respectively (P ＞ 0.05).Perioperative outcomes and follow-up data were compared between the two matched groups.Results There was no significant differences resulted regarding operating time [(127.0 ±54.8)min vs.(130.0 ±49.9) min],blood loss[(166.0 ± 173.5)ml vs.(124.0 ± 101.0)ml],ischemia time [(18.9 ± 6.4) vs.(18.1 ± 5.8) min],hospital stay [(8.7 ± 3.4) d vs.(8.5 ± 2.5) d],incidences of complications (28.6％ vs.19.0％),surgical conversions (0 vs.2.4％),transfusions (4.8％ vs.2.4％) or positive surgical margin(0 vs.0) and malignant pathological outcomes(95.2％ vs.92.9％).The follow-up durations ranged from 3 to 24 months with a mean duration of 9.1 and 12.4 months in SAC and MAC,respectively.At the end of follow-up,the two groups had similar decrease in estimated glomerular filtration rate [(7.5 ± 17.2) ％ vs.(12.1 ± 18.2) ％,P =0.466],but the difference was statistically significant with ECT-GFR both of function reduction in the operated kidney [(21.6 ± 14.6) ％ vs.(38.4 ± 20.7)％,P =0.001] and in two kidneys [(2.5 ±16.4)％ vs.(14.8 ±20.0)％,P =0.002].Conclusions Robotic partial nephrectomy with selective vascular control lead to better postoperative renal function compared with main vascular clamped PN techniques and does not lead to a higher surgical risk following a strict patient selection criteria.
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Objective To summarize our clinical experience of cryoablation for renal cancer and to analyze the therapeutic indication,security,selection of cryoablation and outcomes.Methods Sixty-four patients suffered with T1a renal cell carcinoma were enrolled in this study from March 2012 to March 2018.Among them,5 cases were senile patients (≥ 80 years),5 cases complicated with other cancers,3 cases complicated with renal insufficiency,4 cases complicated with decompensated cirrhosis,3 cases with bilateral renal cancer,4 cases with solitary kidney cancer and 39 cases with some other complications.The preoperative serum creatinine level was(80.5 ± 38.2)μmol/L.The patients underwent laparoscopic singlesite (LESS) renal cryoablation,conventional laparoscopic renal cryoablation,or percutaneous image-guided cryoablation according to individual situation.Contrast-enhanced CT scan or MRI were used during the procedures and follow-up was performed.Results All operations were completed successfully and technical success was achieved as well in all cases.Blood transfusion was necessary for 2 cases because of hemorrhage.The mean diameter of the mass was (2.6 ± 0.90) cm,the median volume of blood loss was 50ml(10-110 ml),and the mean operation time was(96.0 ± 24.5) min.The median inpatient hospital stay was 3 d (1-6 d).In one case,digital subtraction angiography (DSA) embolization was performed due to hemorrhage after surgery.None of the other cases had intraoperative or postoperative complications.The serum creatinine level after surgery was not significantly decreased [postoperative (83.8 ±42.1) μmol/L,P =0.64].The contrast-enhanced CT or MRI of the kidneys one week postoperatively showed uniform low density in all lesion areas,which represented complete ablation and regression of the tumor.All cases were followed up regularly.One case showed relapse at the 6 th month follow-up and underwent cryoablation again.Another case,who was not regularly followed up,relapsed at 69th month after surgery.No relapse was observed in the other cases during the follow-up.Conclusions Renal cancer cryoablation is a safe,feasible and efficacious therapy for the patients who suffered from unresectable T1a renal cell carcinoma because of high surgical risk or multifocal lesions.
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Objective To investigate the safety and efficiency of robot-assisted partial nephrectomy (RAPN) for totally intrarenal tumors (TITs).Methods Thirty-eight patients who underwent RAPN for treating TITs by one experienced surgeon were included between August 2012 and December 2017.There were 25 males and 13 females,aged 26-72 years(mean 51.6 years).Tumors of 24 cases were in right kidney,and 14 cases in left kidney.The diameter of tumor was(3.12 ± 0.92) cm,the R.E.N.A.L.score was(9.76 ± 1.00),and the Scr was (74.82 ± 20.32) μmol/L.Patients' peri-operative and oncological outcomes were analyzed.Results All the tumors were successfully resected without conversion to open surgery or radical nephrectomy.Mean operative time and ischemia time were (188.47 ± 46.75) min and (24.32 ± 7.69) min.Mean blood loss was (115.79 ± 43.66) rrd.One-week postoperative Scr was (85.97 ± 28.33) μmol/L.Postoperative hemorrhage was successfully treated by DSA or drug therapy in 3 patients.The pathological examination showed 28 clear cell renal cell carcinomas,3 chromophobe renal cell carcinomas,3 TFE-3 infusion related renal cell carcinomas,2 metanephric adenomas,1 acidophile adenoma and 2 angioleiomyolipomas.One positive surgical margin occurred in RAPN group for cystic components.No evidence of tumor progression observed during follow-up.Conclusions RAPN is safe and effective in treating TITs when performed by an experienced surgeon at a high-volume institution.Further prospective and large-scale study was warranted to evaluate the long-term outcomes.
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Objective To compare the operative-postoperative outcomes of laparoscopic and robotassisted partial nephrectomy (LPN and RAPN) for patients with T1 b renal masses.Methods A total of 169 T1 b renal mass patients receiving LPN (n =69) or RAPN (n =100) in our center between October 2009 and October 2017 were retrospectively collected.There were 46 males and 23 females in LPN group,with a mean age of (55.0 ± 11.9) years.The mean tumor size was (5.09 ± 0.76) cm,and mean R.E.N.A.L score was 6.36 ± 1.53.49 procedures (71％) were performed via a retroperitoneal approach in LPN group.There were 59 males and 41 females in RAPN group with a mean age of (52.9 ± 11.7) years.The mean tumor size was(4.95 ±0.66) cm,and mean R.E.N.A.L score was 8.17 ± 1.50.31 procedures (31％)were performed via a retroperitoneal approach in RAPN group.There was statistical significance between two groups in R.E.N.A.L score and surgery approach (P ＜ 0.001).The group covariates were balanced through propensity score matching (PSM) using 1∶ 1 nearest neighbor matching method.After PSM,operating time,estimated blood loss,warm ischemia time,incidence of complications,hospital stay and postoperative follow-up status were compared between LPN(n =36)and RAPN(n =36)group.Results After PSM,patient distributions were closely balanced.In the LPN vs the RAPN group,there were significant different in warm ischemia time [(23.9 ± 7.3) min vs.(20.4 ± 6.7) min,P ＜ 0.05],estimated blood loss [(136.9 ± 80.2) ml vs.(136.9 ± 80.2) ml,P ＜ 0.05],incidence of complications (8.7％ vs.1.0％,P ＜0.05),and hospital stay [(11.5 ±3.8)d vs.(9.8 ± 1.80)d].There was no significant differences resulted regarding operating time [(164.5 ± 64.4) min vs.(169.0 ± 42.5) min,P ＞ 0.05],variation of estimated glomerular filtration rate from baseline [(9.97 ± 8.98)％ vs.(9.27 ± 9.19)％,P ＞ 0.05],positive surgical margin rate (1.4％ vs.0,P ＞ 0.05) and rate of recurrence or metastasis (1.4％ vs.1.4％,P ＞ 0.05) between groups.Conclusion Considering operative,functional and oncologic outcomes,both RAPN and LPN performed by an experienced surgeon were acceptable for patients with T1b renal masses.If available,robotic approach may reduce operative trauma and complications.
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Objective This study is to investigate the safety,feasibility and efficacy of the complete retroperitoneal robotic nephroureterectomy in treatment of upper urinary tract tumors.Methods Three patients underwent complete retroperitoneal robotic nephroureterectomy due to the upper urinary epithelial tumor from August to October in 2017 in our institution.The 3 patients' demographics and tumor characteristics,including age,gender,body mass index (kg/m2),ASA score,Charlson comorbidity index,tumor laterality and diameter (cm),were 48/75/68 years old,male/female/female,22.9/20.8/21.3,2/2/2,0/2/1,left/right/left,3.2/2.0/1.4,respectively.All patients had complained about the hematuria and accepted the abdominal CT and CTU examination,preoperatively.All patients were diagnosed localized upper urinary tract malignant tumors based on these images.The tumor of case 1 located in the renal pelvis.The tumor of case 2 located in the upper segment of the ureter.The tumor of case 3 located in the lower segment of the ureter.The operations were performed under general anesthesia,and patients were positioned in full flank.A total of five ports were used in the procedure and placed in the following order.The initial port (Port 1) was a robotic camera port,which was placed 3 cm above the intersection of the mid axillary line and the iliac crest.The next three ports (Port 2 to Port 4) were all 8 mm robotic instrument ports and placed at the intersection of posterior axillary line and costal margin,3 cm above the intersection of anterior axillary line and costal margin,and 4 cm medial and inferior to anterior superior iliac spine.The fifth port (Port 5) was a 12 mm assistant port and placed at 3 cm medial and superior to anterior superior iliac spine.Our completely robotic technique did not require patient repositioning and port reassignment,but redocking of the robotic arms was needed.Nephrectomy was performed according to the routine retroperitoneal laparoscopic procedure.Once the remainder of the kidney was mobilized,the dissection was directed down the pelvis to mobilize the distal segment of the ureter.The bladder defect was then closed by Endo-GIA stapler or absorbable sutures.Results All procedures were successful and smooth,with no intraoperative or postoperative complications.Operative duration (min) and estimated blood loss (ml) was 245/270/239,100/100/100,respectively.Postoperative pain measured by the visual analog pain scale(VASP) at day 1,day 2,day 3 was 5/4/4,4/3/3,2/2/1,respectively.Time off oral intake (d),duration of drainage (d),active time post-operation (h) and hospital stay (d) was 2/2/2,3/2/3,24/32/32,3/2/4,respectively.Intravesical chemotherapy was performed within 24 h after the operation.Postoperatively,the urinary catheter was left in place for 2 weeks.Pathological examination confirmed papillary urothelial carcinoma in all cases.Conclusions The initial experience shows that the complete retroperitoneal robotic nephroureterectomy is a safe,feasible and efficacious procedure,but in this early stage the clinical indications should be strictly controlled.
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Objective To investigate the role and possible mechanism of Chemokine receptor CXCR4 in the drug resistance of sorafenib in renal cell carcinoma.Methods 786-O cells were inoculated into the anterior sciatic region of nude mice subcutaneously,5 × 106 cells per point.The mice were given normal saline and sorafenib intragastric (80 mg/kg,1 time/day) when the transplanted tumor volume reached about 100 mm3.The tumor volume in the saline group was more than 1 500 mm3 at the 5th week,and the tumor was taken as the control tissue.Sorafenib group tumors started to grow accelerately at week 8,and the tumor volume was more than 1 500 mm3 at week 13.The 13th week tumors were used as resistant tissue.The expression of CXCR4 in control tissues and drug resistant tissues was detected by real-time quantitative PCR,western blotting and immunohistochemistry.The pcDNA3.1-CXCR4 plasmid was constructed and transfected into 786-O cells.The expression of CXCR4 was detected by real-time quantitative PCR and western blotting.The drug reactivity of the cells was measured by CCK-8 and monoclonal assay to compare the drug resistance of the control group,CXCR4 overexpression group and CXCR4 overexpression + CXCR4 inhibitor AMD3100 group.The phosphorylation of PKB,ERK and STAT3 in the control group,the sorafenib alone group,the overexpressing CXCR4 + sorafenib group and the overexpressing CXCR4 + sorafenib + AMD3100 group were deternined by Western blotting.Results Compared with the control tissues,the mRNA levels of CXCR4 in the drug-resistant tissues increased (3.22 ± 0.23) times,and the levels of protein expression increased (2.33 ± 0.47) according to western blotting,the differences were statistically significant (P ＜ 0.01).After overexpression of CXCR4,the nRNA expression of CXCR4 increased (78.3 ± 5.3) times,and the protein expression level increased (2.80 ± 0.95) times,and the differences were statistically significant (P ＜ 0.01),indicating that the expression model was established successfully.The drug response curves of the control group,CXCR4 overexpression group and CXCR4 overexpression + AMD3100 group on sorafenib were measured by cck8 method,and the ICS0 was (7.5 ±0.8) μmo]/L,(10.3 ±0.7) μmol/L,(5.7 ±0.6) μmol/L,the differences were statistically significant (P ＜ 0.05);The numbers of clones formed in the above three groups were 26 ± 5,56 ± 12 and 42 ± 9,respectively.The differences were statistically significant (P ＜ 0.05).Sorafenib could reduce the phosphorylation of PKB,ERK and STAT3,and overexpression of CXCR4 could reverse the inhibition of phosphatidylation of PKB,ERK and STAT3 by sorafenib.After inhibition of chemokine receptor CXCR4 activity by AMD3100,PKB,ERK,STAT3 phosphorylation was re-suppressed.Conclusions CXCR4 can promote renal cell carcinoma sorafenib resistance.The expression of CXCR4 increased in secondary resistant tumor tissue increased;CXCR4 may promote drug resistance by activating the cell viable pathway.The inhibition of CXCR4 signaling pathway is expected to improve the therapeutic effect of sorafenib in renal cell carcinoma.
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Objective To explore the clinical utilization value of regional blood flow fluorescence visualization in selective arterial clamping robotic partial nephrectomy.Methods 12 cases of robotic partial nephrectomy with indocyanine green-based regional blood flow fluorescence visualization selective arterial clamping between October 2016 and June 2017 by our team were retrospectively analyzed.There were 9 males and 3 females with age between 36-78 years,mean age(51.2 ± 11.0) years,BMI 20.1-36.2 kg/m2,mean of (25.6 ± 4.8) kg/m2,tumor diameter 2.0-5.1 cm,mean of(3.3 ± 0.9) cm,and R.E.N.A.L.score 4-10,mean(7.3 ± 2.0).Preoperative renal function status of eGFR (estimated glomerular filtration rate) was 82-133 ml/(min · 1.73 m2),mean (101.9 ± 13.7)ml/(min · 1.73 m2) and split ECT-GFR of 44.5-70.6 ml/min,mean of(53.8 ± 8.5) ml/min in operated kidney;48.2-71.1 ml/min,mean of(56.8 ±6.8) ml/min in contralateral kidney;in total,92.7-139.1 ml/min,mean of(109.8 ± 14.6)ml/min.Perioperative information including operative time,blood loss,warm ischemia time,surgical complications,pathologic outcomes and follow-up data of included patients were analyzed.Results All procedures were done smoothly without open or radical conversion,with operative time of 95-203 min,mean of (170.6 ±38.6)min,and estimated blood loss of 60-1 000 ml,mean of(178.3 ± 206.9)ml.According to the visualize uptake of fluorescence imaging perfusion area visualization after selective arterial clamping,1 case underwent unclamping robotic partial nephrectomy,1 case converted to main renal artery clamping with warm ischemia time of 18 min,10 cases performed via renal arterial branch clamping with an average ischemia time of (25.5 ± 10.5) (range 17-46)min,1 of which due to parenchymal bleeding obscuring visualization necessitated clamping of the main renal artery with 1000 ml blood loss,46 min of arterial branch occlusion and 16 min of main artery clamping.The average postoperative hospital stay was (5.8 ± 0.9) (range 5-8)days,and the duration of drainage was (3.5 ± 0.5) (range 3-4) days.No postoperative complications occurred.Postoperative pathology:all margins were all negative,11 cases of clear cell carcinoma,eosinophilic adenoma in 1 case.The average eGFR of 9 cases of renal arterial branch clamping was (94.5 ±22.5)(range 56-140)ml/(min · 1.73 m2) at discharge with a 5％ percentage decrease versus preoperative level.Among them,4 cases obtained with ECT-GFR data 1 month postoperatively had a mean of(37.6 ±13.2)(range 20.8-55.8) ml/min with 29％ percentage decrease on the surgical side,an average of (58.5 ± 6.9) (range 51.2-68.4) ml/min with 2％ compensatory increase of the contralateral side,and (98.7 ± 16.2) (range 79.3-124.3) ml/min in total with a 10.4％ overall decrease.Conclusions The visualization of blood flow imaging based on indocyanine green fluorescence can clearly and intuitively show the effect of branching arterial occlusion in robotic partial nephrectomy,guide the optimization of surgical resection strategy,and improve safety and clinical outcome.
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Objective This study is to explore the safety,feasibility and efficacy of robotic laparoendoscopic single-site(LESS) zero-ischemia partial nephrectomy.Methods Two patients underwent robotic laparoendoscopic single-site zero-ischemia partial nephrectomy by our urologic surgical team at 22-May-2017 and 31-May-2017 in our institution.The salient patient demographics and tumor characteristics,including age,gender,body mass index (kg/m2),Charlson Co-morbidity Index (Age-weighted),tumor laterality,diameter (cm),R.E.N.A.L.nephrometry score and preoperative split renal function GFR [ml/(min · 1.73 m2)] were:73/56,female/male,25.2/19.8,2/0,lcft/right,1.8/1.4,5a/4a,left 43.8、right 49.2/left 38.8 、right 48.7 respectively.A 2-3 cm longitudinal skin incision was made at 4 cm below the inferior margin of rib arch at the level of midaxillary line (case NO.1) or peri-umbilicus (case NO.2).The da Vinci Si robotic Single-siteTM Port was inserted.The line of Toldt was incised with the colon medially mobilized.Gerota's fascia was opened,the main renal artery or its branches were dissected,then the renal mass fully dissected and exposed.The renal mass was entirely removed with approximately 0.5-1.0 cm surrounding normal renal parenchyma (unclamping in case NO.1,and selective branch clamping in case NO.2) and kidney reconstruction was conducted with 1-0 Quill Suture via hem-o-lock sliding technique.Results The two procedures were smoothly completed without any extra skin incision.Operative duration,estimated blood loss and skin incision length was respectively 230/190 min,100/60 ml,3.6/2.5 cm.Duration of two selective renal artery branches clamping in case NO.2 was 39 and 24 min.Postoperative pain measured by the visual analog pain scale (VASP) at day 1,day 2,day 3 was 5/4,3/3,2/1,Time off oral intake,duration of drainage and length of stay after surgery was 2/4 d、2/4 d、6/7d,respectively.The recovery of both patients were uncomplicated and discharged smoothly.Pathological examination revealed oncocytoma in case NO.1 and papillary renal cell carcinoma in case NO.2.Conclusions The initial experience shows the robotic laparoendoscopic single-site zero-ischemia partial nephrectomy is a safe,feasible and efficacious procedure.It may exhibit clinical benefits for patients in terms of pain control,convalescence and cosmesis,but in this early stage the clinical indications should be strictly controlled.
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Objective To determine the significance of the quantitative parameters obtained from intravoxel incoherent motion ( IVIM) diffusion weighted imaging ( DWI) in differentiating renal tumors from normal renal tissues.Methods Twenty-four patients with surgical pathology-proven renal tumors and 13 volunteers with healthy kidneys were included.DWI was performed with 9 b-values (0, 20, 50, 100, 200, 400, 600, 800 and 1 000 s/mm2).The slow component of diffusion (Dslow), fast component of diffusion ( Dfast ) and fraction of fast ADC ( f) of the biexponential DWI were calculated for the clear cell renal cell carcinoma (CCRCC), the normal renal parenchyma and the non CCRCC ( NCCRCC) .The ADC was calculated for all b-values using linear regression yielding standard ADC ( ADCtot ) .The parameters were compared among the groups, and the receiver operating characteristic ( ROC ) analysis was performed. Results CCRCC showed higher ADCtot (1.73 ±0.43) ×10 -3 mm2/s, Dfast (14.75 ±14.73) ×10 -3 mm2/s, Dslow(1.34 ±0.38) ×10 -3 mm2/s than NCCRCC (ADCtot(1.23 ±0.26) ×10 -3 mm2/s, Dfast(9.47 ± 5.27) ×10 -3 mm2/s, Dslow(0.58 ±0.15) ×10 -3 mm2/s), and the differences of ADCtot(P=0.037) and Dslow(P=0.001) were significant.The normal renal parenchyma showed higher ADCtot (2.25 ±0.11) × 10 -3 mm2/s, Dslow ( 1.74 ±0.17 ) ×10 -3 mm2/s, f ( 35.00% ±9.37%) than CCRCC ( f, 31.13% ± 10.75%) and NCCRCC(f, 33.76%±24.02%), and the differences between the normal renal parenchyma and CCRCC of ADCtot ( P =0.000 ) and Dslow ( P =0.001 ) were significant.There were no differences between the normal renal parenchyma and the tumor ipsilateral renal parenchyma of all parameters.Dslow had higher accuracy ( sensitivity 95%, specificity 100%) in distinguishing CCRCC and NCCRCC, with area under the curve of 0.988.Conclusions Multi-b-value DWI derived quantitative parameters including ADCtot and Dslow may differ significantly between the renal tumor and normal renal parenchyma.Dslow is the best parameter in distinguishing CCRCC and NCCRCC.
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Objective To investigate the cause,treatment and prevention of delayed gastric emptying (DGE) after operation for esophageal carcinoma.Methods The clinical data of 13 cases with DGE after operation for esophageal carcinoma were analyzed retrospectively.Results DGE occurred at 10th day after operation.10 cases with functional delayed gastric emptying(FDGE) recovered after conservative treatmeut.3 cases with mechanical delayed gastric emptying(MDGE) were given surgical treatment.Conclusions The anatomical displacement of stomach may be the main cause of DGE.DGE is also related to vagus nerve and postoperative inadequate gastrointestinal decompression.Clinical symptoms,X-ray barium meal radiography and gastroscopy examination are the important diagnostic method.Conservative treatment should be the first choice for FDGE.The use of some gastro-intestinal prokinetic drugs may have a beneficial effect on FDGE.Once the diagnosis of MDGE is established,surgical treatment should be performed as early as possible.The fully preoperative preparation,the precise and concise techniques in operation and postoperative appropriate management may decrease the occurrence of DGE.
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Objective To evaluate the status of urological laparoendoscopic single-site surgery (LESS) technique in China. Methods We had conducted a systematic review of literatures of urological laparoendoscopic single-site surgery published from Chinese institutions using WanFang,CNKI,VIP,CBM,GoogleScholar and MEDLINE databases.All relevant articles were selected with consensus and analyzed according to the inclusion and exclusion criteria. Results Overall,205 articles from 66 different centers all over China published between January 2009 and June 2012 were included in the analysis. Of which,there were 26 articles of science citation index papers and 179 articles from Chinese academic journals.The included literature was mainly composed of case series reports ( 133 articles,64.9％ ),comparison studies (13 articles,6.3％ ),reviews or comments (20 papers,9.8％ ),nursing related papers (28 pieces,13.7％ ),animal surgery studies (6 articles,2.9％ ),and training (5 articles,2.4％ ).A total of 1790 clinical cases were reported during the study period,56.9％ of these were procedures done in the upper urinary tract,only 5.8％ were in the lower urinary tract,and 37.3％ were genital or other procedures.Procedures of tumor-related and reconstruction required accounted for 18.8％ and 18.7％,respectively.Pure single-port technique was applied on 58.3％ of cases.In cases of a single-port platform used,45.6％ used the commercially available devices and 54.4％ used homemade devices.Transperitoneal accesses were adopted in 59.5％ of cases and the other 40.5％ were performed through extraperitoneal approaches.The umbilicus was used as the site of access in 58.5％ of cases.A total of 25 indications were reported,including adrenalectomy,nephrectomy and ureterolithotomy,etc. in the upper urinary tract,radical cystectomy,radical prostatectomy and transvesical enucleation of the prostate,etc.in the lower urinary tract,and varicocelectomy,orchidopexy and others. The three most often done procedures were varicocelectomy (601 cases,33.6％ ),renal cyst decortication (408 cases,22.8％ ) and adrenalectomy ( 179 cases,10.0％ ).The overall conversion rate was 5.5％,and complications were encountered in 3.4％ of cases. Conclusions Laparoendoscopic single-site surgery has been widely adopted by Chinese urologists and largely covered the spectrum of conventional urologic laparoscopic procedures,with most of these being non-reconstructive operations for the treatment of benign diseases.In large,we are still under the initial stage of LESS application in urology.And more work on creative innovation and well-designed studies are needed to further evaluate its role in the urological minimally invasive surgery.
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Objective To report a 4-year cumulative series (209 cases) of laparoendoscopic singlesite surgery (LESS) in urology and assess its clinical utilization. Methods Consecutive LESS cases done between December 2008 and July 2012 at our institution were prospectively recorded and retrospective analyzed in this study.Demographic data,main perioperative outcomes,and information related to the surgical technique were collected and analyzed.There were 209 patients ( 121 males and 88 females) with a mean age of (52.8 ±14.5) years,a mean B MIof (23.5 ±3.12) kg/m2 and a mean ASA score of (2.0±0.3).20.1％ (42 cases) of patients had previous abdominal or pelvic surgeries.29.2％ (61 cases) and 12.9％(27 cases) of patients had diabetes mellitus and hypertension. Indications were renal tumors (70 cases,33.5％),adrenal tumors (42,20.1％),renal cyst (22 cases,10.5％),ureteral calculi (22 cases,10.5％),nonfunctional kidneys (19 cases,9.1％),BPH (10 cases,4.8％),and others (24 cases,11.5％ ).Surgical conversions were evaluated,as well as intraoperative and postoperative complications.Two periods were arbitrarily dcfined:the first was from December 2008 to Septcmber 2010 (22 mon) and the second.was from October 2010 to July 2012 (22 mon).A comparative analysis between these two periods was conducted. Results There were 209 LESS surgeries included in this study.Most common procedures ( 92.3％ ) were done on the upper urinary tract,with 55.5％ of the whole cohort being tumor-related indications and only 16.3％ being reconstructive procedures.The transperitoneal approaches were preferentially adopted in 80.9％ cases,and transvesical access in 5.3％ cases. The transumbilical access was used in 46.9％ of cases.The overall conversion rate was 8.1％,with 4.3％ of cases converted to reduced - port laparoscopy,1.9％ to conventional laparoscopy,and 1.9％ to open surgery.The intraoperative complication rate was 4.8％ ( 10/209 ) and postoperative complications,mostly low grade,were encountered in 11.5％(24/209) of cases.There was a significant increase in the number of LESS cases during the second study period; the rate of some procedures (ie,transumbilical LESS,renal cyst decortication and transvesical single-port enucleation of the prostate) was lower,whereas some other procedures were performed more frequently (ie,tumor-related LESS procedures,radical nephrectomy and adrenalectomy). Conclusions A broad range of urological procedures can be finished with LESS technique in the experienced hands of a laparoscopic surgeons.However,LESS is still in its infancy with a certain risk of surgical complication and conversion.Stringent patient selection criteria should be applied,especially during the learning curve.Complex reconstructive procedures or malignant tumor related indications are not appropriate as the start of this kind of procedure.We need always put patient's safety and treatment efficacy first.
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Objective To summarize the clincical experience of transumbilical Laparoendoscopic Single-site (LESS) nephrectomy and to evaluate its safety and efficacy. Methods From December 2008 to August 2010, we have performed 20 cases of transumbilical LESS nephrectomy by Tri-Port system, of which 9 patients underwent LESS radical nephrectomy (left 8, right 1, stage T1 ), 1 patient underwent LESS radical resection of right ureteral carcinoma, 10 patients underwent LESS simple nephrectomy (left 5, right 5). The Tri-Port system was inserted transperitoneally through a 2 cm umbilical incision. A 5-mm 30° telescope was introduced through the port to visualize the operative field. Flexible equipment and standard laparoscopic equipment were used to perform the procedures.The incisions were extended to about 6cm in order to remove the specimens. Results Conversion to open surgery was necessary in one LESS radical resection of right ureteral carcinoma and one LESS simple nephrectomy, while the remaining 18 cases were successful (the addition of a single 5-mm port was necessary in 2 cases of LESS radical nephrectomy). The mean operative time was 197 min (85-510 min), mean estimated blood loss was 126 ml (50-400 ml), without blood transfusion in the perioperative period, mean postoperative hospital stay was 6.3 d (3-14 d), and mean duration of catheter drainage was 3.6 d (0- 14 d). Conclusions Transumbilical LESS nephrectomy is feasible, safe,minimally invasive and cosmetic. Long-term follow-up and a clinical control study are needed for evaluating clinical outcomes.