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1.
Chinese Journal of Urology ; (12): 339-343, 2022.
Article in Chinese | WPRIM | ID: wpr-933229

ABSTRACT

Objective:To investigate the efficacy and safety of laparoscopic partial nephrectomy in the treatment of renal tumors with renal score of 10.Methods:From February 2016 to March 2021, 23 patients who underwent laparoscopic partial nephrectomy in Peking University Third Hospital with renal tumors of R. E.N.A.L. score of 10 was studied retrospectively, including 16 cases of male and 7 cases of female, with 11 cases on the right side and 12 cases on the left side. The patients’ age was (55.0±16.4) years, and BMI was (25.4±3.6) kg/m 2. The maximum diameter of the tumor was (3.5±1.4)cm. Laparoscopic partial nephrectomy was performed after complete examination. The observation indexes included operation time, blocking time, complications, postoperative hospital stay and the trifecta (negative surgical margin, blocking time ≤25 minutes, and no perioperative complications). Results:All operations were successfully completed, only 4 cases were converted to open surgery. The median operation time was 153 min(99-346 min). The median blocking time was 27 min(14-60min). The median postoperative hospital stay was 6 d(4-11 d). Postoperative complications occurred in 7 cases(fever in 5 cases, intestinal obstruction in 1 case, postoperative blood transfusion and leg intermuscular venous thrombosis in 1 case). 9 cases (39.1%) achieved the trifecta. 19 cases who completed by laparoscopy, their operation time was 151 min(99-303 min), blocking time was 28 min(18-60 min), postoperative hospital stay was 6 d(4-11 d), fever occurred in 4 cases, and 6 cases achieved the trifecta (31.6%). The follow-up time was 3-62 months, with a median of 32 months, and there was no recurrence or metastasis.Conclusions:Laparoscopic partial nephrectomy is safe and effective in the treatment of renal tumors with renal score of 10.Although the tumor is highly complex, it also achieves the purpose of preserving nephron to the greatest extent. If technical conditions permit, laparoscopic partial nephrectomy could be considered for the treatment of highly complex renal tumors.

2.
Chinese Journal of Urology ; (12): 330-334, 2022.
Article in Chinese | WPRIM | ID: wpr-933227

ABSTRACT

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.

3.
Chinese Journal of Urology ; (12): 91-95, 2022.
Article in Chinese | WPRIM | ID: wpr-933169

ABSTRACT

Objective:To investigate the correlation between preoperative platelet parameters and clinicopathological features of renal cell carcinoma.Methods:The data of 452 patients with renal cell carcinoma treated in the Peking University Third Hospital from January 2015 to December 2016 were retrospectively analyzed, including 308 males and 144 females, and the mean age was 56.5(15-86) years. There were 178 cases, 72 cases, and 42 cases combined with hypertension, diabetes, and coronary heart disease, respectively. Preoperative platelet parameters were the mean PLT of 218.56(72-568)×10 9/L, MPV of 9.65(6.2-20.5)fl, PDW of 14.44(7.9-23.1) fl, and PCT of 20.72%(8%-49%). The data of 253 patients with simple renal cysts were selected as the controls, including 140 males and 113 females, and the mean age was 58(9-84) years. There were 178 cases, 72 cases, and 42 cases combined with hypertension, diabetes, and coronary heart disease, respectively. Preoperative platelet parameters were the mean PLT of 207.08(84-362)×10 9/L, MPV of 9.50(6.9-13.9)fl, PDW of 14.59(8.9-21.6)fl, and PCT of 19.49%(9%-36%). Propensity score matching method was used to balance the baseline differences between the two groups, and the differences of platelet parameters between the two groups were compared. The correlation between different clinicopathological characteristics of renal cell carcinoma and platelet parameters was analyzed. Multivariate logistic regression model was used to explore the risk factors of renal cell carcinoma with lymph node or distant metastasis. Results:After matching the baseline data, PLT( t=1.993, P=0.047) and PCT( t=2.396, P= 0.017) in renal cell carcinoma group were significantly higher than those in controls. Among 452 cases in renal cell carcinoma, there were 395 cases (87.4%) with clear cell renal cell carcinoma and 57 cases (12.6%) with non-clear cell renal cell carcinoma. For pathological stage, there were 325 cases (71.9%) of T 1-T 2 stage and 127 cases (28.1%) of T 3-T 4 stage. In addition, there were 444 cases (98.2%) of N 0 stage, 8 cases (1.8%) of N 1 stage, 428 cases (93.6%) of M 0 stage, and 24 cases (6.4%) of M 1 stage. There were 320 cases of nuclear grade Ⅰ-Ⅱ, 99 cases of nuclear grade Ⅲ-Ⅳ, and 33 cases without nuclear grade. Preoperative high PLT was significantly correlated with T 3-T 4( t=3.409, P=0.001), M 1( t=2.772, P=0.011) and nuclear grade Ⅲ-Ⅳ( t=2.859, P=0.005). Low MPV was significantly correlated with M 1( t=2.981, P=0.003). Low PDW was correlated with T 3-T 4( t=2.567, P=0.011). High PCT was significantly correlated with T 3-T 4( t=2.722, P=0.007) and nuclear grade Ⅲ-Ⅳ( t=3.011, P=0.003). Multivariate logistic regression analysis showed that PLT( OR=1.007, 95% CI 1.002-1.012, P=0.009), clear cell renal cell carcinoma( OR=4.467, 95% CI 1.574-12.679, P=0.005)and nuclear grade Ⅲ-Ⅳ( OR= 5.554, 95% CI 2.399-12.856, P<0.001)were independent risk factors for lymph node or distant metastasis of RCC. Conclusions:PLT and PCT are higher in patients with renal cell carcinoma compared to simple renal cysts. High PLT, PCT, and low MPV, PDW are correlated with the poor clinicopathological characteristics of renal cell carcinoma. Preoperative PLT can be used as an independent risk factor for lymph node or distant metastasis of renal cell carcinoma.

4.
Article in Chinese | WPRIM | ID: wpr-931367

ABSTRACT

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.

5.
Chinese Journal of Urology ; (12): 38-42, 2021.
Article in Chinese | WPRIM | ID: wpr-884955

ABSTRACT

Objective:To explore the application of real-time transrectal ultrasound (TRUS) during seminal vesiculoscopy in infertile men with azoospermia or oligoasthenospermia.Methods:We retrospectively analyzed the clinical data of 25 cases of azoospermia or oligoasthenospermia due to ejaculate ducts obstruction who were treated with real-time transrectal ultrasound-guided seminal vesiculoscopy between September 2011 and December 2015. Patients’ age was(29.4±4.5) years. All patients accepted semen analysis, serum sex hormone, MRI, TRUS and then diagnosed as obstructive azoospermia, and 13 cases had intractable obstructive azoospermia or oligoasthenospermia after the failure of simple seminal vesiculoscopy(the path to the ejaculatory duct and seminal vesicle couldn’t be found). All patients were treated with seminal vesiculoscopy under real-time guidance with TRUS. We assessed the success rate of surgery, surgical time and complications.Results:The scope was successfully inserted into the seminal vesicle in 21 of the 25 cases (success rate, 84%). The median operative time was 75(31, 148) min. None of the patients developed severe complications. Among 4 failure cases (4/25, 16%), 1 was due to abnormal congenital development. In 2 cases, a clear outlet of the dual ejaculatory duct could not be found after it was inserted into the prostatic utricle. One case was considered as a Müllerian tubular cyst, and the seminal vesicle scope was used to assess the cystic side wall. The 21 patients were followed up for 3 to 6 months, semen volume 2.0(0-5.2)ml, total sperm 28(0-832) ×10 6/ejaculate, sperm density 5.6(0-110.3)×10 6/ml, mobility rate of sperm 5.4%(0-63.6%), and the differences were significant as compared to that before the surgery [semen volume 0.4(0-2.8)ml, total sperm 0(0-342)×10 6/ejaculate, sperm density 0(0-90.7)×10 6/ml, mobility rate of sperm 0(0-24.1%), all P<0.05]. Among the 17 patients who underwent follow-up of 5 to 9 years, 3 patients was conceived naturally and 9 patients’ postoperative sperm quality has improved and pregnancy in vitro fertilization by extracting sperm from semen. Conclusions:Intraoperative real-time transrectal ultrasound guidance can improved the success rate of seminal vesiculoscopy and promoted operative safety.

6.
Chinese Journal of Urology ; (12): 566-570, 2021.
Article in Chinese | WPRIM | ID: wpr-911073

ABSTRACT

Objective:To disiuss the application of liver free technique in renal cell carcinoma patients with Mayo Ⅱ-Ⅳ tumor thrombus.Methods:The clinical data of renal cell carcinoma patients with MayoⅡ-Ⅳ IVC tumor thrombus in our hospital from January 2014 to December 2019 were retrospectively analyzed. 25 patients underwent right part of liver or hepatic portal part dissection via open abdominal approach. There were 20 males and 5 females, aged 45-74 years (mean 61±6 years). All patients underwent urinary tract CTU or MRU examination, vena cava enhanced magnetic resonance angiography.There were left 8 cases, right 17 cases; the median length of tumor was 7 cm (3.6-12.1 cm). There were 1 case of Mayo grade Ⅱ tumor thrombus, 7 cases of Mayo grade Ⅲ tumor thrombus, and 17 cases of Mayo grade Ⅳ tumor thrombus. There were 7 cases of distant metastasis, including 6 cases of lung metastasis and 1 case of bone metastasis. After multi-disciplinary consultation (MDT), 19 patients underwent radical nephrectomy and 6 patients underwent tumor reducing nephrectomy. During the operation, the ligaments around the liver were completely dissociated and the space between the liver and kidney was opened. The bare area of the liver was fully dissociated, to expose the inferior vena cava. For Mayo grade Ⅳ tumor thrombus, 11 cases were treated with free diaphragmatic thrombus removal without thoracotomy, and 6 cases were treated with open chest cardiopulmonary bypass.Results:The median operation time was 444(258-694)min, the median intraoperative blood loss was 2 000(250-10 000)ml, and the median value of suspended red blood cell transfusion was 1 300(400-10 400)ml. The median postoperative hospital stay was 10(4-25)days.15 patients (60%) had postoperative complications, including 8 cases of liver injury, 5 cases of respiratory complications, 4 cases of kidney injury, 3 cases of anemia, 3 cases of infection and 1 case of thrombosis. Three patients died during perioperative period.Conclusions:The application of total liver free technique might obtain good exposure of surgical field, effectively control the hemorrhage of inferior vena cava, which is helpful for safe resection of tumor.

7.
Chinese Journal of Urology ; (12): 414-422, 2021.
Article in Chinese | WPRIM | ID: wpr-911043

ABSTRACT

Objective:To assess the efficacy and safety of 100 units of botulinum toxin A (BTX-A) intradetrusor injection in patients with overactive bladder.Methods:From April 2016 to December 2018, 17 tertiary hospitals were selected to participate in this prospective, multicenter, randomized, double-blind, placebo-controlled study. Two phases of study were conducted: the primary phase and the extended phase. This study enrolled patients aged 18 to 75 years who had been inadequately managed by anticholinergic therapy (insufficient efficacy or intolerable side effects) and had spontaneous voiding with overactive bladder. Exclusion criteria included patients with severe cardiac, renal and hepatic disorders, patients with previous botulinum toxin treatment for 6 months or allergic to BTX-A, patients with urinary tract infections, patients with urinary stones, urinary tract tumors, diabetes mellitus, and bleeding tendency. Eligible patients were randomly assigned to BTX-A group and placebo control group in a ratio of 2∶1. Two groups of patients received 20 intradetrusor injections of BTX-A 100U or placebo at the depth of the submucosal muscle layer respectively under cystoscope, including 5 injections at the base of the bladder, 3 injections to the bladder triangle, 5 injections each to the left and right walls and 2 injections to the top, sparing the bladder neck. As a placebo control group, patients received same volume of placebo containing no BTX-A and only adjuvant freeze-dried preparations for injection with the same method. A combination of gelatin, sucrose, and dextran served as adjuvants. Average micturition times per 24 hours, urinary incontinence (UI) episodes per day, average micturition volume per day, OAB symptom score(OABSS), and quality of life (QOL) score were recorded at baseline and the 2nd, 6th and 12th week after treatment. The primary efficacy endpoint was the change from baseline in the average micturition times per 24 hours at the 6th week after treatment. The secondary efficacy endpoints included the change from baseline in the average micturition times per 24 hours at 2nd and 12th week, as well as the change from baseline in the OABSS, QOL score, average frequency of urgency and UI episodes per day, urgency score, average micturition volume per day at 2nd, 6th and 12th week after treatment. Patients were followed for 12 weeks to assess adverse events (AEs). After assessed at week 12, if the micturition times has decreased less than 50% compared to baseline and the patient is willing to receive retreatment, then patients could enter the extended trial phase. In that phase, patients in both groups were injected with 100 units BTX-A from 12th week onwards and then followed up the same indicators for 12 weeks.Results:216 patients were enrolled in this trial (144 cases in the BTX-A group and 72 cases in the placebo control group). Baseline characteristics such as age (47.75±14.20 in the BTX-A group and 46.39±15.55 in the control group), sex (25 male/117 female in the BTX-A group and 10/61 in the control group), and disease duration (0.51 years in the BTX-A group and 0.60 years in the control group) were balanced between the two groups( P>0.05). A marked reduction from baseline in average micturition times per 24 hours was observed in all treatment groups at the 6th week and the reduction of the two groups was statistically different ( P<0.001 and P=0.008 respectively). Compared with the baseline, the average micturition times per 24 hours at the 6th week decreased from baseline by 2.40(0.70, 4.60)times for the BTX-A group and 0.70(-1.00, 3.30) times for the placebo control group respectively, and the difference between the two groups was considered to be statistically significant ( P=0.003). The change rates of average micturition times per 24 hours from baseline at the 6th week of the two groups were (16±22)% and (8±25)% respectively, and the difference between the two groups was statistically significant ( P=0.014). Compared with the baseline, the average micturition times per 24 hours at 2nd and 12th week decreased by 2.00(0.00, 4.00)and 3.30(0.60, 5.03)for the BTX-A group, 1.00(-1.00, 3.00)and 1.70(-1.45, 3.85)for the placebo control group respectively. The difference between two groups was considered to be statistically significant ( P=0.038 and P=0.012); the changes of average urgency times per day for the BTX-A group and the control group at the 2nd, 6th and 12th week were 2.00(0.00, 4.30)and 2.40(0.30, 5.00), 3.00(0.30, 5.70)and 0.70(-1.30, 2.70), 0.70(-1.30, 3.00) and 1.35(-1.15, 3.50), respectively. There were significant differences between two groups at the 2nd, 6th and 12th week, ( P=0.010, P=0.003 and P=0.025, respectively). The OABSS of the BTX-A group and the control group at the 6th week decreased by 1.00(0.00, 4.00)and 0.50(-1.00, 2.00) compared with the baseline, and the difference between the two groups was statistically significant ( P=0.003). 47 cases of BTX-A group and 34 cases of placebo control group entered the extended trial phase, and 40 and 28 cases completed the extended trial phase, respectively. The average micturition volume per 24 hours changed by -16.60(-41.60, -0.60)ml and -6.40(-22.40, 13.30)ml, (-35.67±54.41)ml and(-1.76±48.69)ml, (-36.14±41.51)ml and (-9.28±44.59)ml, (-35.85±43.35)ml and(-10.41±40.29)ml for two groups at the 12th, 14th, 18th and 24th week, and the difference between two groups was statistically significant at each follow-up time ( P=0.01, 0.006, 0.012 and 0.016, respectively). There was no significant difference in other parameters( P>0.05). However, adverse reactions after intradetrusor injection included increased residual urine volume (27 in the BTX-A group and 3 in the control group), dysuria (21 in the BTX-A group and 6 in the control group), urinary infection (19 in the BTX-A group and 6 in the control group), bladder neck obstruction (3 in the BTX-A group and 0 in the control group), hematuria (3 in the BTX-A group and 1 in the control group), elevated alanine aminotransferase (3 in the BTX-A group and 0 in the control group), etc. During the follow-up period, there was no significant difference in the other adverse events between two groups except the increase of residual urine volume( P<0.05). In the primary trial phase, among the 27 cases with increased residual urine volume in BTA group, only 1 case (3.70%) with PVR more than 300 ml; the PVR of 3 patients in the placebo group was less than 100 ml. The increase of residual urine volume caused by the injection could be improved or disappeared with the passage of time. Conclusions:Intradetrusor injection of Chinese BTX-A improved the average micturition times per 24 hours, the average daily urgent micturition times, OABSS, and average micturition volume per time, and reduced the adverse effects in patients with overactive bladder.Chinese BTX-A at dose of 100U demonstrated durable efficacy and safety in the management of overactive bladder.

8.
The Korean Journal of Pain ; : 208-215, 2020.
Article | WPRIM | ID: wpr-835232

ABSTRACT

Zoster sine herpete (ZSH) is one of the atypical clinical manifestations of herpes zoster (HZ), which stems from infection and reactivation of the varicella-zoster virus (VZV) in the cranial nerve, spinal nerve, viscera, or autonomic nerve. Patients with ZSH display variable symptoms, such as neuralgia, however, different from HZ, ZSH show no zoster, which makes clinical diagnosis difficult. ZSH not only causes initial symptoms, such as neuropathic pain in the affected nerve, Bell palsy, and Ramsay Hunt syndrome, but also postherpetic neuralgia and fatal complications such as VZV encephalitis and stroke. The misdiagnosis of ZSH and tardy antiviral treatment may lead to severe ZSH sequelae. We review the publications related to ZSH, especially its diagnosis with VZV DNA and/or anti-VZV immunoglobulin (IgG and IgM). More work about ZSH, especially ZSH epidemiological survey and guidelines for its diagnosis and treatment, are needed because most of the present studies are case reports.

9.
Chinese Journal of Urology ; (12): 873-876, 2020.
Article in Chinese | WPRIM | ID: wpr-869764

ABSTRACT

Liquid biopsy is a noninvasive analysis of tumor related substances in fluid samples, which overcomes the limitations of traditional histological biopsy, and beneficial for early diagnosis and differentiation, prediction of response to treatment, longitudinal monitoring of disease progression and prediction of prognosis. Renal cell carcinoma is lack of mature serum tumor markers, and the diagnosis and monitoring of the disease still rely on imaging. In recent years, liquid biopsy has become a hotspot in renal cell carcinoma. In this paper, we will review the application and research progress of circulating tumor cells (CTCs), circulating tumor DNA (ctDNA), circulating tumor RNA (ctRNA), exosomes, tumor "education" platelets (TEPs) in renal cell carcinoma.

10.
Chinese Journal of Urology ; (12): 656-660, 2020.
Article in Chinese | WPRIM | ID: wpr-869741

ABSTRACT

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.

11.
Chinese Journal of Urology ; (12): 497-502, 2020.
Article in Chinese | WPRIM | ID: wpr-869702

ABSTRACT

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.

12.
Chinese Journal of Urology ; (12): 415-420, 2020.
Article in Chinese | WPRIM | ID: wpr-869682

ABSTRACT

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.

13.
Chinese Journal of Urology ; (12): 474-476, 2020.
Article in Chinese | WPRIM | ID: wpr-869674

ABSTRACT

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.

14.
Chinese Journal of Urology ; (12): 430-433, 2020.
Article in Chinese | WPRIM | ID: wpr-869672

ABSTRACT

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.

15.
Chinese Journal of Urology ; (12): 267-271, 2020.
Article in Chinese | WPRIM | ID: wpr-869646

ABSTRACT

Objective:To evaluate the feasibility, safety and efficacy of single-stage percutaneous nephrolithotomy (PCNL) combined with flexible ureteroscopy (FURS) for the management of staghorn calculi with pyonephrosis.Methods:A total of 13 patients of staghorn renal calculi with pyonephrosis, which was diagnosed by intraoperative pelvic urine bacteria culture, were treated by PCNL combined with FURS from May 2017 to December 2019. Of all the 13 patients, 7 were males and 6 were females, with mean age of 52.5 years, ranged from 33 years to 68 years. The mean stone burden was (1 070.9±397.0) mm 2, ranged from 507.4 mm 2 to 1 809.5 mm 2. Bacteria culture and microbial sensitivity test was performed for all the patients. Four patients with fever on admission accepted ureteral stenting at least a week before the surgeries. All the patients received preoperative antibiotic therapies for at least a week, and the infective symptoms and inflammatory indexes was normal before the surgeries. Under general anesthesia, the procedures were performed in a modified supine Valdivia position. After the transurethral FURS was performed, the standard percutaneous track was placed at the subcostal point between mid-axillary line and scapular line under the FURS and ultrasounic guide. The purulence and the stones were shattered and removed by PCNL with negative pressure system, and FURS helped to shatter and move out the stones beyond the PCNL reach through the same tract. A double-J tubes and a nephrostomy tube was routinely indwelled postoperatively. A radiological imaging was performed within three days after the operation to evaluate the stone free rate. The residual stone was defined as the stone larger than 4 mm. Results:All the procedures were successful. The one-stage stone free rate was 76.9% (10/13). The mean operation time was (94.2±21.8) min, ranged from 65 to 135 min. Six patients suffered postoperative systemic inflammatory response syndrome, and no patient occurred sepsis or complications of Clavien-Dindo classification Ⅲ or above. They were followed up for 3-24 months with median of 12 months.Four cases with recurrence of ipsilateral stones, two cases with ipsilateral mild renal atrophy, no recurrent ipsilateral upper uninary infection were found in the followup.Conclusions:Single-stage PCNL combined with flexible ureteroscopy could be feasible for the management of staghorn calculi with pyonephrosis with safety and efficacy.

16.
Chinese Journal of Urology ; (12): 205-209, 2020.
Article in Chinese | WPRIM | ID: wpr-869629

ABSTRACT

Objective:To establish a nomogram model for predicting positive resection margins after prostate cancer surgery, and to perform the corresponding verification, in order to predict the risk of positive resection margins after surgery.Methods:A total of 2 215 prostate cancer patients from The First Affiliated Hospital of Naval Medical University, Hospital, Peking University First Hospital, Peking University Third Hospital, Peking University, and First Affiliated Hospital of Xi′an Jiaotong University were included in the PC-follow database from 2015 to 2018, and a simple random sampling method was used. They were divided into 1 770 patients in the modeling group and 445 patients in the verification group. In the modeling group, the age (<60 years, 60 to 70 years, >70 years), PSA (<4 ng/ml, 4-10 ng/ml, 11-20 ng/ml, >20 ng/ml), pelvic MRI (negative, suspicious, positive), clinical stage of the tumor (T 1-T 2, ≥T 3), percentage of positive needles (≤33%, 34%-66%, >66%), Gleason score of biopsy pathology (≤6 points, 7 points, ≥8 points). Univariate and multivariate logistic analysis were performed to screen meaningful indicators to construct a nomogram model. The model was used for validation in the validation group. Results:The results of multivariate analysis showed that preoperative PSA level ( OR=2.046, 95% CI 1.022 to 4.251, P=0.009), percentage of puncture positive needles ( OR=1.502, 95% CI 1.136 to 1.978, P=0.002), Gleason score of puncture pathology ( OR=1.568, 95% CI 1.063 to 2.313, P=0.028), pelvic MRI were correlated ( OR=1.525, 95% CI 1.160 to 2.005, P=0.033). Establish a nomogram model for independent predictors of positive margin of prostate cancer. The area under the receiver operating characteristic (ROC) curve of the validation group is 0.776. The area under the ROC curve of the preoperative PSA level, percentage of puncture positive needles, puncture pathology Gleason score, pelvic MRI, postoperative pathology Gleason score were 0.554, 0.615, 0.556, 0.522, and 0.560, respectively. The difference between the nomogram model and other indicators was statistically significant ( P<0.05). Conclusions:The constructed nomogram model has higher diagnostic value than the preoperative PSA level, percentage of puncture positive needles, Gleason score of puncturing pathology, pelvic MRI, and postoperative pathological Gleason score in predicting positive margin.

17.
Chinese Journal of Geriatrics ; (12): 1059-1062, 2020.
Article in Chinese | WPRIM | ID: wpr-869528

ABSTRACT

Objective:To investigate the risk factors for Gleason score upgrading after radical prostatectomy in clinical low-risk prostate cancer patients aged≥65 years.Methods:A total of 485 clinical low-risk prostate cancer patients aged≥65 years at five centers of the national multi-center PC-follow database from January 2015 to March 2019 were retrospectively analyzed.Data including age at diagnosis, prostate-specific antigen(PSA), MRI prostate imaging, puncture Gleason score, operation method, puncture method, positive incision margin and capsule penetration were collected.Differences in Gleason scores before and after operation were compared, and the risk factors for Gleason score upgrading after radical resection were evaluated by univariate and multivariate Logistic regression analysis.Results:Of 485 patients with a puncture Gleason score of 3+ 3=6, 261(53.8%)cases had postoperative pathological upgrading, in whom 228(87.4%)cases had Gleason score upgrading of 7, 22(8.4%)had Gleason score upgrading of 8, and 11(4.2%)had Gleason score upgrading of 9 or more.The rate of Gleason score upgrading was elevated with increased preoperative PSA levels, positive pelvic MRI, and higher positive rates of puncture biopsy.The incidences of postoperative capsule penetration(27.2% vs.12.5%, P<0.001)and positive incision margin(25.2% vs.17.4%, P=0.036)had statistically significant differences between the pathologically upgraded group and the pathologically non-upgraded group.Multivariate analysis showed that preoperative PSA level, percentage of positive puncture biopsies, biopsy Gleason score and pelvic MRI were independent predictors of prostate cancer. Conclusions:For clinical low-risk prostate cancer patients aged≥65 years with high risk factors for Gleason score upgrading, repeated biopsies should be carried out when necessary and the treatment plan should be adjusted accordingly.

18.
Chinese Journal of Oncology ; (12): 760-764, 2019.
Article in Chinese | WPRIM | ID: wpr-796932

ABSTRACT

Objective@#To investigate the incidence and clinical characteristics of urothelial carcinoma (UC) accompanied with multiple primary carcinoma (MPC).@*Methods@#The clinical data of 121 UC patients with MPC in Peking University Third Hospital from January 2010 to May 2018 were retrospectly analyzed.@*Results@#UC patients with MPC accounted for 9.74% (121/1 242) of all the UC patients. The ratio of male to female patients was 2.10∶1 in the total MPC patients, but it was 1∶1 in the upper urinary tract MPC subgroup. The MPC patients were more common in elderly people, whose medium age was 68 (32-93) years old. Of all the location (131 person-time) of other tumors besides UC, the digestive system tumors occurred most frequently, accounting for 41.98% (55/131), followed by the urinary and male reproductive system tumors (20.61%, 27/131) and the female reproductive system (12.21%, 16/131). The proportion of the digestive system tumors (47.37%, 9/19) was the highest in the upper urinary tract MPC, with a total number of the other primary cancer of 19 person-time. However, the proportion of the urinary and male reproductive system tumors (37.14%, 13/35) was higher in the synchronous MPC group, with a total number of the other primary cancer of 35 person-time. Some patients had a history of radiotherapy and/or chemotherapy before UC was diagnosed. We also observed 2 cases of genetically confirmed Lynch syndrome. The median overall survival (mOS) of UC patients with MPC was 132 months, and the mOS of patients with UC as the first malignancy (including synchronous MPC and UC as the first malignancy in metachronous MPC) was 120 months. The mOS of the synchronous MPC group was 84 months, which was significantly shorter than 178 months of metachronous MPC group (χ2 =14.029, P<0.001).@*Conclusions@#The incidence of UC accompanied with MPC is not low, and the most common sites of MPC are the digestive system and reproductive system. Therefore, screening for MPC in UC patients, especially those with personal or family history of tumors, as well as elderly patients, may help early diagnosis and treatment of MPC patients and improve their prognoses.

19.
Chinese Journal of Urology ; (12): 732-736, 2019.
Article in Chinese | WPRIM | ID: wpr-796744

ABSTRACT

Objective@#To explore the clinical characteristics of renal angiomyolipoma (AML) with inferior vena cava (IVC) tumor thrombus and to improve the diagnosis and treatment of the disease.@*Methods@#The clinical data of 3 patients with renal AML and inferior vena cava tumor thrombus was retrospectively reviewed. The patients were all female, aged 19 to 70 years. Among them, 2 patients presented with lumbago on the right side, and the other one was diagnosed by physical examination. The body mass index ranged from 18.4 to 24.6 kg/m2, with a median value of 20.4 kg/m2. According to the American Society of Anesthesiologists (ASA), they were classified as grade Ⅱ. Color doppler ultrasound examination of the kidney and IVC was performed in all the 3 patients, all of which showed hyperechoic solid mass in the right kidney. Color doppler ultrasound of IVC showed hyperechoic band in the IVC, indicating blood flow signals and the tumor thrombus. All the 3 cases showed irregular fat density or mixed density in the right kidney and multiple irregular fat density were observed in the right renal vein and inferior vena cava on CT. Two of them received MRI examination of IVC, which showed irregular lesions in the right kidney, short T1 and long T2 signals, low lipids, and no definite limited diffusion on DWI. Irregular fat signal were seen in the right renal vein and inferior vena cava. All 3 patients were diagnosed with right renal mass with IVC tumor thrombus, with 1 patient of Mayo grade Ⅲ tumor thrombus and the other 2 of Mayo gradeⅡtumor thrombus. One underwent laparoscopic radical nephrectomy and inferior vena cava tumor thrombectomy, another one underwent open right partial nephrectomy and tumor thrombectomy, and the third one suffered preoperative AML rupture, undergoing open radical nephrectomy and tumor thrombectomy.@*Results@#The operation time was 168 to 659 min, with median of 220 min. Intraoperative blood loss ranged from 50 to 300 ml, with the median of 50 ml. Postoperative indwelling time of drainage tube was 5 to 11 days, with the median of 6 days. Postoperative hospital stay ranged from 7 to 14 days, with a median of 8 days. Postoperative follow-up ranged from 12 to 16 months, with a median follow-up of 13 months. All the three patients underwent operation without postoperative complications. Postoperative pathology proved to be right renal angiomyolipoma. After 3 months of follow-up, the patients showed no tumor recurrence or metastasis.@*Conclusions@#Renal AML is a benign lesion, which is rarely concurrent with inferior vena cava cancer thrombus. Enhanced CT examination is the main diagnostic method, surgical resection of the lesion is the preferred treatment, partial nephrectomy combined with thrombectomy can be performed in patients with AML, if permitted, and postoperative prognosis turns out to be propitious.

20.
Chinese Journal of Urology ; (12): 732-736, 2019.
Article in Chinese | WPRIM | ID: wpr-791676

ABSTRACT

Objective To explore the clinical characteristics of renal angiomyolipoma (AML) with inferior vena cava (IVC) tumor thrombus and to improve the diagnosis and treatment of the disease.Methods The clinical data of 3 patients with renal AML and inferior vena cava tumor thrombus was retrospectively reviewed.The patients were all female,aged 19 to 70 years.Among them,2 patients presented with lumbago on the right side,and the other one was diagnosed by physical examination.The body mass index ranged from 18.4 to 24.6 kg/m2,with a median value of 20.4 kg/m2.According to the American Society of Anesthesiologists (ASA),they were classified as grade Ⅱ.Color doppler ultrasound examination of the kidney and IVC was performed in all the 3 patients,all of which showed hyperechoic solid mass in the right kidney.Color doppler ultrasound of IVC showed hyperechoic band in the IVC,indicating blood flow signals and the tumor thrombus.All the 3 cases showed irregular fat density or mixed density in the right kidney and multiple irregular fat density were observed in the right renal vein and inferior vena cava on CT.Two of them received MRI examination of IVC,which showed irregular lesions in the right kidney,short T1 and long T2 signals,low lipids,and no definite limited diffusion on DWI.Irregular fat signal were seen in the right renal vein and inferior vena cava.All 3 patients were diagnosed with right renal mass with IVC tumor thrombus,with 1 patient of Mayo grade Ⅲ tumor thrombus and the other 2 of Mayo grade Ⅱ tumor thrombus.One underwent laparoscopic radical nephrectomy and inferior vena cava tumor thrombectomy,another one underwent open right partial nephrectomy and tumor thrombectomy,and the third one suffered preoperative AML rupture,undergoing open radical nephrectomy and tumor thrombectomy.Results The operation time was 168 to 659 min,with median of 220 min.Intraoperative blood loss ranged from 50 to 300 ml,with the median of 50 ml.Postoperative indwelling time of drainage tube was 5 to 11 days,with the median of 6 days.Postoperative hospital stay ranged from 7 to 14 days,with a median of 8 days.Postoperative follow-up ranged from 12 to 16 months,with a median follow-up of 13 months.All the three patients underwent operation without postoperative complications.Postoperative pathology proved to be right renal angiomyolipoma.After 3 months of follow-up,the patients showed no tumor recurrence or metastasis.Conclusions Renal AML is a benign lesion,which is rarely concurrent with inferior vena cava cancer thrombus.Enhanced CT examination is the main diagnostic method,surgical resection of the lesion is the preferred treatment,partial nephrectomy combined with thrombectomy can be performed in patients with AML,if permitted,and postoperative prognosis turns out to be propitious.

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