Predictive model of early urinary continence recovery based on prostate gland MRI parameters after laparoscopic radical prostatectomy / 北京大学学报(医学版)

OBJECTIVE@#Constructing a predictive model for urinary incontinence after laparoscopic radical prostatectomy (LRP) based on prostatic gland related MRI parameters.@*METHODS@#In this study, 202 cases were included. All the patients were diagnosed with prostate cancer by prostate biopsy and underwent LRP surgery in Peking University Third Hospital. The preoperative MRI examination of all the patients was completed within 1 week before the prostate biopsy. Prostatic gland related parameters included prostate length, width, height, prostatic volume, intravesical prostatic protrusion length (IPPL), prostate apex shape, etc. From the first month after the operation, the recovery of urinary continence was followed up every month, and the recovery of urinary continence was based on the need not to use the urine pad all day long. Logistic multivariate regression analysis was used to analyze the influence of early postoperative recovery of urinary continence. Risk factors were used to draw the receiver operator characteristic (ROC) curves of each model to predict the recovery of postoperative urinary continence, and the difference of the area under the curve (AUC) was compared by DeLong test, and the clinical net benefit of the model was evaluated by decision curve analysis (DCA).@*RESULTS@#The average age of 202 patients was 69.0 (64.0, 75.5) years, the average prostate specific antigen (PSA) before puncture was 12.12 (7.36, 20.06) μg/L, and the Gleason score < 7 points and ≥ 7 points were 73 cases (36.2%) and 129 cases (63.9%) respectively, with 100 cases (49.5%) at T1/T2 clinical stage, and 102 cases (50.5%) at T3 stage. The prostatic volume measured by preoperative MRI was 35.4 (26.2, 51.1) mL, the ratio of the height to the width was 0.91 (0.77, 1.07), the membranous urethral length (MUL) was 15 (11, 16) mm, and the IPPL was 2 (0, 6) mm. The prostatic apex A-D subtypes were 67 cases (33.2%), 80 cases (39.6%), 24 cases (11.9%) and 31 cases (15.3%), respectively. The training set and validation set were 141 cases and 61 cases, respectively. The operations of all the patients were successfully completed, and the urinary continence rate was 59.4% (120/202) in the 3 months follow-up. The results of multivariate analysis of the training set showed that the MUL (P < 0.001), IPPL (P=0.017) and clinical stage (P=0.022) were independent risk factors for urinary incontinence in the early postoperative period (3 months). The nomogram and clinical decision curve were made according to the results of multivariate analysis. The AUC value of the training set was 0.885 (0.826, 0.944), and the AUC value of the validation set was 0.854 (0.757, 0.950). In the verification set, the Hosmer-Lemeshow goodness-of-fit test was performed on the model, and the Chi-square value was 5.426 (P=0.711).@*CONCLUSION@#Preoperative MUL, IPPL, and clinical stage are indepen-dent risk factors for incontinence after LRP. The nomogram developed based on the relevant parameters of MRI glands can effectively predict the recovery of early urinary continence after LRP. The results of this study require further large-scale clinical research to confirm.

Relationship between recovery of urinary continence after laparoscopic radical prostatectomy and preoperative/postoperative membranous urethral length / 北京大学学报(医学版)

OBJECTIVE@#To evaluate the relationship between recovery of urinary continence after laparoscopic radical prostatectomy (LRP) and preoperative/postoperative membranous urethral length (MUL) on magnetic resonance imaging.@*METHODS@#We retrospectively analyzed 69 patients with pathologic confirmed prostate carcinoma who underwent laparoscopic radical prostatectomy. Preoperative MUL was defined as the distance from the apex of prostate to the level of the urethra at penile bulb on the coronal image. Postoperative MUL was defined as the distance from the bladder neck to the level of the urethra at the penile bulb on the coronal image. MUL-retained rate was defined as the percentage of postoperative MUL to preoperative MUL. All patients received extraperitoneal LRP. Patients reported freedom from using safety pad (0 pad/d) were defined as urinary continence. Multivariate Logistic regression analyses were used to identify independent predictors of early continence recovery after LRP. Kaplan-Meier analyses and log-rank test were used to compare time to continence recovery between the groups.@*RESULTS@#For all the 69 patients, the average age was (71.4±8.6) years. The prostate specific antigen before biopsy was (23.40±30.31) μg/L, and the mean preoperative prostatic volume by magnetic resonance imaging was (39.48±22.73) mL. The mean preoperative MUL was (13.0±3.3) mm, the mean postoperative MUL was (12.3±3.4) mm, and the mean MUL-retained rate was 93.9%±6.2%. The continence rate for all the patients after LRP was 57.9% and 97.1% in three months and one year, respectively. The patients achieving early continence recovery had significant smaller prostatic volume (P=0.028), longer preoperative MUL and postoperative MUL (P < 0.001). Multivariate Logistic regression analyses revealed postoperative MUL (P < 0.001) were predictors of continence recovery after LRP. Kaplan-Meier analyses and Log-rank test revealed that preoperative MUL (≥14 mm vs. < 14 mm, P < 0.001) and postoperative MUL (≥13 mm vs. < 13 mm, P < 0.001), MUL-retained rate (< 94% vs. ≥94%, P < 0.001) were all significantly associated with continence recovery.@*CONCLUSION@#Post-operative MUL was independently predictors of early continence recovery after LRP. Preoperative MUL, postoperative MUL and MUL retained rate were significantly associated with recovery of urinary continence.

Surgical strategy selection and experience summary of prostate cancer with positive single needle biopsy / 北京大学学报(医学版)

OBJECTIVE@#To analyze the clinicopathological characteristics of prostate cancer patients undertaking radical prostatectomy with single positive core biopsy, and to optimize the rational choice of therapeutic strategy.@*METHODS@#In the study, 53 patients with single positive core prostate biopsy and treated by radical prostatectomy from January 2010 to December 2018, were analyzed retrospectively. The mean age was (69.7±6.9) years (54-81 years), the mean prostate specific antigen (PSA) level was (9.70±5.24) μg/L (1.69-25.69 μg/L), and the mean prostate volume was (50.70±28.39) mL (12.41-171.92 mL). Thirty-nine out of 54 (73.6%) patients presented Gleason score with 6, 11 patients (20.8%) had Gleason score of 7 and 3 patients (5.7%) showed Gleason score ≥8. For clinical stages, 6 out of the 53 patients (11.3%) had prostate cancer in cT1, 44 cases (83.0%) had prostate cancer in cT2, and 3 cases (5.7%) in cT3.The patients were divided into subgroups according to age, preoperative PSA level, Gleason score, percentage of tumor in single needle tissue and clinical stage, and the differences of their clinicopathological characteristics were compared.@*RESULTS@#Postoperative Gleason score of 6, 7 and ≥8 were found in 20 cases (37.7%), 21 cases (39.6%) and 10 cases (18.9%) respectively, another 2 cases (3.8%) were pT0 prostate cancer; pathological stages of T0, T2a, T2b, T2c and T3 were found in 2 cases (3.8%), 9 cases (17.0%), 2 cases (3.8%), 29 cases (54.7%) and 11 cases (20.8%) respectively; 11 cases (20.8%) had positive surgical margin, 10 cases (18.9%) had extracapsular invasion of prostate, and 1 case (1.9%) showed seminal vesicle invasion. Forty-two cases (79.2%) had multifocal lesions and 37 cases (69.8%) presented bilateral lesion. Compared with the biopsy Gleason score, the postoperative Gleason score was downgrated in 3 cases (5.7%), unchanged in 28 cases (52.8%), and upgraded in 20 cases (37.7%), of which 2 cases (3.8%) were pT0. Compared with the clinical stage, the postoperative pathological stage decreased in 2 cases (3.8%), unchanged in 10 cases (18.9%), and upgraded in 41 cases (77.4%). According to the postoperative pathology, the patients were divided into two groups: microfocus cancer group (n=8) and non-microfocus cancer group (n=45). The difference between the two groups in the percentage of tumor in the single-needle tissue ≤5% was statistically significant (P=0.014). Other parameter diffe-rences including age, prostate volume, and preoperative prostate special antigen density (PSAD) and Gleason scores were not statistically significant (P>0.05). The method to determine the location of cancer at the apex of prostate according to biopsy results showed 41.4% (12/29) false negative rate and 50.0% (12/24) false positive rate. There was statistically significant difference between the actual cases of lymph node dissection and reserved nerve and the cases of scheme selection in theory according to the postoperative pathology (P < 0.05).@*CONCLUSION@#The proportion of single needle cancer tissue less than or equal to 5% is a predictor of prostate microfocal cancer. 37.7% cases had pathological upgrading and 77.4% cases had pathological staging upgrading. When choosing the operation scheme, such as sexual nerve reserved, lymph node dissection and apex operation skill, it is necessary to comprehensively analyze multiple factors, such as tumor risk classification, prediction factors of nomogram, multi-parameter MRI and intraoperative situation and so on.

Low power seven-step two-lobe holmium laser enucleation of the prostate technique for surgical treatment of benign prostatic hyperplasia / 北京大学学报(医学版)

OBJECTIVE@#To evaluate the safety and efficacy of the seven-step two-lobe holmium laser enucleation of the prostate (HoLEP) technique with low power laser device, and to introduce the detailed operating procedures, key points, short-term outcomes of this modified HoLEP technique.@*METHODS@#From March 2016 to November 2017, 90 patients underwent HoLEP in Peking University Third Hospital. The patients were divided into two groups: high-power group (32 patients) were performed with traditional Gilling's three-lobe enucleation using high power (90 W) laser; Low-power group (58 patients) were performed with seven-step two-lobe enucleation using low power (40 W) laser. The main steps of the low power seven-step two-lobe HoLEP phase included: (1) The identification of the correct plane between adenoma and capsule at 5 and 7 o'clock laterally to the veru montanum; (2) The connection of the bilateral plane by making a adenoma incision at the proximal point of veru montanum; (3) The extension of the dorsal plane under the whole three lobes between adenoma and capsule towards the bladder neck; (4) The separation of the middle lobe from two lateral lobes by making two retrograde incisions separately from apex 5 and 7 o'clock towards the bladder neck; (5) The enucleation of the middle lobe adenoma by extending the dorsal plane through into the bladder; (6) The prevention of the apex mucosa by making a circle incision at the apex of the prostate; (7) The en-bloc enucleation of the two lateral lobe adenomas by extending the lateral and ventral plane between adenoma and capsule from 5 and 7 o'clock to 12 o'clock conjunction and through into the bladder.@*RESULTS@#The mean patient age was (66.25±5.37) years vs. (68.00±5.18) years; The mean body mass indexes were (24.13±4.06) kg/m2 vs. (24.57±3.50) kg/m2; The mean prostate specific antigen values were (3.23±2.47) μg/L vs. (6.00±6.09) μg/L; The average prostatic volumes evaluated by ultrasound was (49.03±20.63) mL vs. (67.55±36.97) mL. There was no significant difference between the two groups. Furthermore, there were no significant differences in terms of perioperative and follow up data, including operative time; enucleation efficiencies; hemoglobin decrease; blood sodium and potassiumthe change postoperatively; catheterization duration and hospital stay; the international prostate symptom scores and quality of life scores pre- and post-operatively. There was 1 transurethral resection of the prostate (TURP) conversion in high-power group and 1 transfusion in low-power group during the operations. The follow-up one month after operation showed no severe stress incontinence in both the groups, whereas 3 cases ejaculatory dysfunctions in high-power group versus 1 case in low-power group were observed; Other surgeryrelated complications included: 2 cases postoperative hemorrhage (Clavien II and Clavien IIIb) in high-power group, 2 cases postoperative temperature more than 38 °C (Clavien I) and 1 case dysuria following catheter removal (Clavien I) in low-power group.@*CONCLUSION@#Low power laser device can be applied safe and effectively for HoLEP procedure using the seven-step two-lobe HoLEP technique. The outcomes comparable with high power laser HoLEP can be achieved.

Transurethral flexible ureteroscopic holmium laser resection for tumors of renal pelvis: 6 cases report and literature review / 北京大学学报(医学版)

OBJECTIVE@#To summarize the experience of flexible ureteroscopic holmium laser resection in treatment of renal pelvic carcinoma and to evaluate its value in treatment of renal pelvic carcinoma.@*METHODS@#The clinical data of 6 patients with renal pelvic carcinoma treated in Peking University Third Hospital from January 2015 to January 2017 were retrospectively analyzed. The 6 patients were treated by the same experienced urologist and by flexible ureteroscopic holmium laser resection of renal pelvic tumors under general anesthesia. Regarding the intensity of the holmium laser, 10-30 W was generally used with settings of 0.5-1.5 J and 10-20 Hz. In general, a 200 μm end-firing holmium laser fiber was used. Narrow-band imaging (NBI) technique was applicated to search for tumors and check whether the excision was satisfactory. Routine "second flexible ureteroscopy" was performed after 4-6 weeks, and suspected lesions were referred for a biopy, then vaporized and cauterized. The ureteroscopy was examined every 6 months after operation, and color Doppler ultrasound, computed tomography urography (CTU) or magnetic resonance urography (MRU) were performed at the same time. The urine tumor cells were examined for 3 days before the operation, and the urine tumor markers, such as urinary nuclear matrix protein 22 (NMP22) were tested. For cases with highisk urothelial carcinoma and normal renal function, and 6 cycles of systemic adjuvant chemotherapy were performed after operation.@*RESULTS@#All of the cases were successfully treated. The data were as follows: the operation time 77.5 min (45-115 min), the blood loss 10 mL (5-20 mL), and hospital stay after surgery 3 days (2-5 days). After 13-34 months' followp, two patients had recurrent tumor recurrence and underwent resection operation. Two patients received systemic adjuvant chemotherapy after operation. Case 5 was histopathologically high grade urothelial carcinoma, and 6 cycles of systemic chemotherapy were given after operation. Local recurrence occurred during chemotherapy, and then endoscopic operation was performed, and no recurrence occurred in the follow-up for 12 months after reoperation. In case 6, the pathology was low grade urothelial carcinoma, but the case was multiple tumors in the right renal calyx and the lower calyx. Then 6 cycles of systemic chemotherapy were given, and no recurrence was found in the followp for 13 months.@*CONCLUSION@#Transurethral flexible ureteroscopic holmium laser resection is relatively safe for the treatment of renal pelvic carcinoma. It is suitable for special cases of solitary kidney and renal dysfunction, as well as for patients with low risk urinary tract epithelial tumors, but the recurrence rate is high, and the indications need to be strictly controlled. Patients with high-risk urothelial carcinoma who underwent endoscopic resection are advised to receive systemic adjuvant gemcitabine and cisplatin (GC) regimen after surgery, in order to increase the overall survival rate. Systemic chemotherapy combined with endoscopic operation may become a new treatment for upper tract urothelial carcinoma (UTUC).

Laparoscopic ureterovesical reimplantation for ureteral stricture after renal transplantation / 北京大学学报(医学版)

OBJECTIVE@#To discuss the safety and efficacy of laparoscopic ureterovesical reimplantation in the treatment of transplanted ureteral stenosis.@*METHODS@#One case of laparoscopic ureterovesicalre implantation in the treatment of ureteral stenosis after renal transplantation was reported, and related literatures was reviewed. A 54-year-old woman was admitted to our hospital with main complaint of hydronephrosis of transplanted kidney for five years after renal transplantation. Her physical examination showed slightly bulging in the transplanted kidney area without tenderness. The magnetic resonance urography (MRU) showed that the transplanted kidney and ureter were dilated obviously, with significant dilatation of renal pelvis and calyx, about 5 cm at the widest point of renal pelvis expansion, and the end of ureter was narrow, without abnormal filling defect in the ureter. The primary diagnosis was distal transplanted ureteral stenosis. After twice endoscopic ureteral dilatation by multi-endoscopic technique, there was no improvement in the hydronephrosis after the removal of the stent. After thorough preoperative preparation, laparoscopic ureterovesical reimplantation was performed under general anesthesia. Firstly, the median umbilical ligament, the lateral umbilical ligament and the peritoneal fold were cut off, and the anterior bladder space was dissociated distally. The space of left side wall of the bladder and the pubic bone was gradually dissociated, and the space of anterior bladder wall and the pubic bone was dissociated. Secondly, the right side wall of the bladder was dissociated from the head to the tail, and the surrounding structure was carefully identified to avoid injury of the ureter of the transplanted kidney. The transplanted ureter was sought between the right side of the bladder and the lower pole of the transplanted kidney. The distal end of the ureter was cut open, and the narrow section was cut off, confirming that no stenosis in the proximal ureter. The ureterocystic anastomosis was performed by Lich-Gregoir method (extra-bladder). Finally, the bladder tissue around the anastomosis site was fixed to the right pelvic wall to reduce tension.@*RESULTS@#The operation was completed successfully, the operation time was 210 min, the amount of bleeding was about 30 mL, and there was no surgical complication. The creatinine was stable after operation, with serum creatinine declining to 68 μmol/L, and serum creatinine 94 μmol/L before operation. The patient was discharged 5 days after operation. After follow-up of 3 months, KUB indicated that the position of ureteral stent was good and the function of renal transplantation was stable.@*CONCLUSION@#Laparoscopic ureterovesical reimplantation is a safe and effective treatment for ureteral ureteral stricture after renal transplantation. Compared with open surgery, laparoscopic surgery has less impact on renal renal allograft, with faster recovery, less bleeding, fewer complications, less postoperative pain and minimally invasive wound. This surgical procedure is difficult and requires an experienced urologist with high laparoscopic skills to perform.

Predicting model based on risk factors for urosepsis after percutaneous nephrolithotomy / 北京大学学报(医学版)

OBJECTIVE@#To analyze the potential perioperative risk factors that affect the development of urosepsis following percutaneous nephrolithotomy (PCNL) for upper urinary tract calculi with a regression model, and to develop a nomogram for predicting the probability of postoperative urosepsis after PCNL according to the identified independent risk factors.@*METHODS@#We retrospectively analyzed the clinical data from consecutive 405 cases of upper urinary tract calculi treated by one-phase PCNL between January 2013 and December 2016 in our clinical department. According to whether the patients developed urosepsis or not after the surgery, the patients were divided into two groups. Perioperative risk factors that could potentially contribute to urosepsis were compared between the two groups. By a Logistic regression model, univariate and multivariate statistical analyses were carried out for the occurrence of postoperative urosepsis, to identify the independent risk factors affecting the development of postoperative urosepsis. From this model, a nomogram was built based on regression coefficients.@*RESULTS@#The PCNL procedures of the 405 cases were performed successfully, and there were 32 cases that developed urosepsis after the PCNL, and the incidence of urosepsis was 7.9% (32/405). A multivariate Logistic regression model was built, excluding the factors with values of P>0.05 in the univariate analysis. Multivariable Logistic regression analysis identified the following factors as independent risk factors for urosepsis after PCNL: diabetes mellitus history (OR=4.511, P=0.001), larger stone burden (OR=2.588, P=0.043), longer operation time (OR=2.353, P=0.036), increased irrigation rate (OR=5.862, P<0.001), and infectious stone composition (OR=2.677, P=0.036). The nomogram based on these results was well fitted to predict a probability, and the concordance index (C-index) was 0.834 in the nomogram model sample and 0.802 in the validation sample.@*CONCLUSION@#Diabetes mellitus history, higher stone burden, longer operation time, increased intraoperative irrigation rate, and infectious stone composition are identified as independent risk factors to affect the development of urosepsis after one-phase percutaneous nephrolithotomy for upper urinary tract calculi. A nomogram based on these perioperative clinical independent risk factors for urosepsis could be used to predict the risk of urosepsis following PCNL.

Inhibitory effect of CMTM5 on xenografted human prostatic cancer in nude mice / 中华男科学杂志

<p><b>OBJECTIVE</b>To investigate the inhibitory effect of CKLF-like MARVEL transmembrane domain containing 5 (CMTM5) on xenografted human prostatic cancer in nude mice and its action mechanism.</p><p><b>METHODS</b>We established a model of xenografted prostatic cancer by inoculating PC-3 cells subcutaneously into nude mice, and 3 weeks later injected CMTM5 adenovirus locally into the tumor followed by daily observation of the tumor volume and body weight of the experimental animals. All the rats were killed 2 weeks after CMTM5 injection and the tumor tissue harvested for detection of the inhibitory effect of CMTM5 on the expressions of VEGF and NF-kappaB proteins by immunohistochemistry.</p><p><b>RESULTS</b>The tumor volume was significantly smaller and body weight of the CMTM5-treated mice were (573.39 +/- 175.24) mm3 and (0.55 +/- 0.11) g, respectively, significantly decreased as compared with those of the controls ([1482.50 +/- 327.86] mm3 and [1.31 +/- 0.29] g) (P = 0.03 and P = 0.027). Immunohistochemistry showed that the expressions of VEGF and NF-kappaB were obviously down-regulated in the CMTM5 group in comparison with the control group.</p><p><b>CONCLUSION</b>CMTM5 suppresses the growth of prostate cancer by down-regulating the expressions of VEGF and NF-kappaB.</p>