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Objective:To evaluate the performance of a novel master-slave transurethral surgical robot system and test its safety and effectiveness.Methods:In September 2021, two urologists (A and B) applied transurethral surgery robot prototype on simulate human tissue model experiments. The transurethral surgical robotic systems used in this study include: master-end control platform, slave-end surgical platform, and end-effector. The main end control platform adopted Omega7 force feedback main hand as the main controller, and the degrees of freedom include: up and down translation, left and right translation, front and back translation, end rotation, end pitch, end swing, end operation. The end-operated surgical platform adopts the Med 7 seven-degree-of-freedom medical collaborative robotic arm to apply precision through the end effector operated resectoscope. The end effectors were modular in design for maximum compatibility with existing surgical instruments. The two doctors routinely assembled the resectoscope and the transurethral surgical robot 20 times each to calculate the assembly time. The routine assembly time of the resectoscope included the time when the lens and light source were connected after the resectoscope had been installed, and the doctor entered the experimental module with the resectoscope in hand. The time to assemble the surgical robot included the time to install the resectoscope with the end effector and connect the lens and light source to enter the experimental module. Two doctors performed 25 simulated prostate resection and 5 simulated bladder resection procedures. The small intestine, heart and stomach of pigs were sutured to construct urethra, prostate and bladder structures that simulated human body: urethra (pig small intestine) was 16-18 cm long, prostate (pig heart) size was about 5 cm×5 cm×6 cm, and bladder (pig stomach) capacity was 250-300 ml. The model was placed in a 3D printed sleeve to simulate the fitting of the urethra to the silicone penis. Prostate resection surgery: the doctor operated the handle on the main end control platform, controld the slave actuator through human-computer interaction, and excisesed the "prostate" around the fixed point under direct vision, simulating standard transurethral prostatectomy, the resection ranges from the bladder neck to the tip of the prostate, and the two lobes and middle lobes were removed. Each operation lasted 40 minutes and the weight of the removed tissue was recorded. Transurethral esection of the bladder: each procedure involved removal of the triangle, bilateral walls, and apical area of the bladder to record the occurrence of perforation. The accuracy of master-slave operating distance, operation attitude accuracy, master-slave operation attitude repeatability, fixed point accuracy, master-slave control start delay time and master-slave control following delay time, robotic arm swing range, limit site and other indicators of the robot were verified by surgery.Results:The positioning accuracy of the end effector of transurethral surgical robot was less than 0.5 mm, the accuracy of master-slave operation distance was ≤0.5 mmthe repeatability distance was ≤0.2 mm, the accuracy of master-slave operation attitude was a≤0.30°, the angle b≤0.30°, the angle C≤0.15°, the accuracy of the fixed point ≤is 0.6 mm, the maximum activity space of the robotic arm was a hemispherical space with a radius of (1 493±5)mm. The delay time of master-slave control startup and master-slave control follow-up delay time did not exceed 100ms; When the end of the manipulator was collided by an external force during the movement, the system could automatically stop the movement of the manipulator, at this time the external force was(70±7) N, and the fixed point setting range was 30-170 mm. The assembly time of transurethral surgery robot by Doctor A and Doctor B was (111.35±57.88) s and (111.70±58.30), respectively.The time of routine assembly resectoscope was (44.90±4.89) s and (44.90±5.16) s, respectively, and the difference between the routine assembly time and robot assembly time of Doctor A and Doctor B were not statistically significant( P=0.679 and P=0.996), the assembly time of the two doctor robots was more than the conventional assembly time( P=0.001 and P=0.001). The average weight of prostate tissue resection in experiments was (43.60±12.42)g and (43.45±12.63)g, respectively. No significant difference was found between them( P=0.954). During the simulated bladder electrosurgery, the robot system could successfully complete the resection of the triangular region, bilateral walls, and top tissues of the bladder. In the surgical experiment, the system operated smoothly, without mechanical failure, module damage, perforation, and other complications. Conclusions:The transurethral surgery robot might be a choice for transurethral surgery.
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Objective:To explore the clinical value of 68Ga-pentixafor PET/CT targeting for CXCR4 in the diagnosis and prognosis evaluation of primary aldosteronism (PA). Methods:Retrospective analysis was performed on information of 72 patients diagnosed with PA who received operations according to the results of 68Ga-pentixafor PET/CT in our hospital. There were 37 males and 35 females, with the average age of (48.3±9.5) years old. The average lesion diameter was (1.60 ± 0.54)cm. The preoperative systolic and diastolic blood pressure were (177.3 ± 23.9)mmHg and (107.6 ± 13.2)mmHg, respectively. The average preoperative potassium level was (2.62 ± 0.56)mmol/L. The average aldosterone concentration was (17.98 ± 4.66)ng/dl, and the median plasma renin activity was 0.01 (0.01, 0.09) ng/(ml·h). All patients underwent 68Ga-pentixafor PET/CT examination, which lead to the decision of surgical strategies. For those patients with single lesion, multiple lesions in one side or positive lesion in one side but negative in the opposite side, surgical resection of the positive side lesion or total adrenalectomy was considered. For those patients with bilateral positive lesions, surgical resection of the side with more significant positive lesions or total adrenalectomy was considered. For those with negative multiple lesions, the surgical strategy was designed according to the results of CT examination or AVS. The positive rate of 68Ga-pentixafor PET/CT and its relationship with the clinical characteristics and prognosis of patients were analyzed. Results:The results of 68Ga-pentixafor PET/CT were positive in 62 of 72 patients diagnosed with PA (86.1%), and the median SUVmax value was 11.1 (7.1, 16.2). The SUVmax value was positively correlated with the maximum diameter of adrenal lesion ( r=0.468) and negatively correlated with blood potassium levels ( r=-0.437), while not significantly correlated with other clinical characteristics. The positive rate of adenoma by 68Ga-pentixafor PET/CT was higher than that of nodular hyperplasia [90.5%(57/63) vs. 55.6%(5/9), P=0.018], and the SUVmax value in adenoma was also higher than that in nodular hyperplasia [11.9(7.8, 16.2) vs. 4.3(3.4, 11.3), P=0.022]. 32 cases were cured after operations, and 37 cases were improved. And 3 cases were not cured. The SUVmax value of lesions in the cured patients was higher than that in the improved patients [15.4(8.1, 22.7) vs. 10.1(6.8, 13.3), P=0.013]. Among 59 cases of PA patients with single adrenal lesions, 50 cases represented positive results of 68Ga-pentixafor PET/CT. 23 cases in 50 positive cases were cured and 27 cases were improved after resection of positive lesions. In the 13 PA patients with multiple adrenal lesions who underwent surgery according to the results of 68Ga-pentixafor PET/CT, 12 patients (92.3%) showed postoperative prognosis in line with preoperative expectations. Conclusions:68Ga-pentixafor PET/CT showed high positive rate in the diagnosis of PA, especially for adenoma.The SUVmax value of the adrenal lesion was correlated with the blood potassium level, the size of the lesion and the postoperative prognosis. In addition, 68Ga-pentixafor PET/CT could effectively guide the surgical decision of PA.
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WHO issued the fifth edition of classification of neuroendocrine neoplasms in 2022. The content of paragangliomas and pheochromocytomas (PPGL) was updated compared with the fourth edition in 2017. In the fifth edition of PPGL classification system, the author redefined the concepts that were vague and unclear in the past, and also put forward some new ideas. On this basis, this article introduces the relevant updates in combination with the current clinical situation in China. The content includes the concept evolution of paragangliomas and pheochromocytomas, accurate interpretation of the definitions of paraganglioid tumor, composite paraganglioma, adrenal medullary hyperplasia, and micro-pheochromocytoma. This article also help readers to understand molecular diagnostic and prognostic markers, the definition and clinical staging of benign and malignant PPGL. The domestic scholars can unify some concepts in PPGL to avoid confusion and facilitate academic exchanges through the discussion of these key concepts.
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Objective:To explore the feasibility of deep learning technology for renal artery recognition in retroperitoneal laparoscopic renal surgery videos.Methods:From January 2020 to July 2021, the video data of 87 cases of laparoscopic retroperitoneal nephrectomy, including radical nephrectomy, partial nephrectomy, and hemiurorectomy, were retrospectively analyzed. Two urological surgeons screened video clips containing renal arteries. After frame extraction, annotation, review, and proofreading, the labeled targets were divided into training set and test set by the random number table in a ratio of 4∶1. The training set was used to train the neural network model. The test set was used to test the ability of the neural network to identify the renal artery in scenes with different difficulties, which was uniformly transmitted to the YOLOv3 convolutional neural network model for training. According to the opinion of two senior doctors, the test set was divided into high, medium, and low discrimination of renal artery and surrounding tissue. High identification means a clean renal artery and a large exposed area. For middle recognition degree, the renal artery had a certain degree of blood immersion, and the exposed area was medium. Low identification means that the exposed area of the renal artery was small, often located at the edge of the lens, and the blood immersion was severe, which may lead to lens blurring. In the surgical video, the annotator annotated the renal artery truth box frame by frame. After normalization and preprocessing, all images were input into the neural network model for training. The neural network output the renal artery prediction box, and if the overlap ratio (IOU) with the true value box was higher than the set threshold, it was judged that the prediction was correct. The neural network test results of the test set were recorded, and the sensitivity and accuracy were calculated according to IOU.Results:In the training set, 1 149 targets of 13 videos had high recognition degree, 1 891 targets of 17 videos had medium recognition degree, and 349 targets of 18 videos had low recognition degree. In the test set, 267 targets in 9 videos had high recognition degree, 519 targets in 11 videos had medium recognition degree, and 349 targets in 18 videos had low recognition degree. When the IOU threshold was 0.1, the sensitivity and accuracy were 52.78% and 82.50%, respectively. When the IOU threshold was 0.5, the sensitivity and accuracy were 37.80% and 59.10%, respectively. When the IOU threshold was 0.1, the sensitivity and accuracy of high, medium and low recognition groups were 89.14% and 87.82%, 45.86% and 78.03%, 32.95%, and 76.67%, respectively. The frame rate of the YOLOv3 algorithm in real-time surgery video was ≥15 frames/second. The false detection rate and missed detection rate of neural network for renal artery identification in laparoscopic renal surgery video were 47.22% and 17.49%, respectively (IOU=0.1). The leading causes of false detection were similar tissue and reflective light. The main reasons for missed detection were image blurring, blood dipping, dark light, fascia interference, or instrument occlusion, etc.Conclusions:Deep learning-based renal artery recognition technology is feasible. It may assist the surgeon in quickly identifying and protecting the renal artery during the operation and improving the safety of surgery.
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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.
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Objective:To compare the outcomes of low-dose-rate prostate brachytherapy (BT) and radical prostatectomy (RP) in patients with T 1c-T 3a prostate cancer. Methods:A group of 745 patients with T 1c-T 3a prostate cancer between January 2010 and August 2017 at Peking Union Medical College Hospital were identified. The records of these patients, who were followed up for a minimum of 2 years, were reviewed. 384 cases received BT. Their characters included age(72.1±6.6), tPSA (12.4±6.1) ng/ml, prostate volume (33.6±13.8) ml, Gleason grade group (2.0±1.2). In this group, T 1c-T 2a stage was diagnosed in 189 cases, T 2b-T 2c stage in 182 cases and T 3a stage in 13 cases.361 cases received RP. Their characters included age(65.7±6.2), tPSA(12.6±6.4) ng/ml, prostate volume (37.2±17.8) ml, Gleason grade group (1.9±1.2). In this group, T 1c-T 2a stage was diagnosed in 177 cases, T 2b-T 2c stage in 170 cases and T 3a stage in 14 cases.The log-rank test compared survival rates between the two modalities, and Cox regression identified factors associated with bRFS. Results:Median follow-up was 60 months. Kaplan-Meier analysis did not show any statistically significant differences in terms of cRFS( P=0.321), cancer specific survival (CSS, P=0.643) and overall survival (OS, P=0.565) rate between the two groups. BT was associated with improved bRFS compared to RP( P=0.018). Risk of biochemical recurrence was significantly lower with BT compared with RP in the patients with a biopsy Gleason grade group 2 and 3 ( P=0.008), or prostate volume ≤35 ml ( P=0.027), or tPSA ≤10 ng/ml ( P=0.013), or the clinical T stages of T 2b and T 2C( P=0.031), or in the intermediate-risk group according to NCCN risk classification ( P=0.003). On multivariate analysis of all 745 patients, age≤ 70 and T stage≥T 2b was associated with significantly shorter bRFS. Conclusions:BT produced equivalent cRFS, CSS and OS compared to RP, while it was associated with improved bRFS. BT On multivariate analysis of all 745 patients, age≤ 70 and T stage≥T 2b was associated with significantly lower bRFS.
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Clinical decision-making has been perceived as a primary cognitive activity for clinicians in daily practice,which based on the process of choosing between alternatives or options for patients.A single clinical decision might affect one patient's health outcomes,while the sum of clinical decisions made by all clinicians would play a decisive role in the allocation and utilization of health resources.Several dimensions should be taken into consideration when making clinical decisions,such as scientificity,clinical experience,economical status,medical humanities and government administration.In addition,clinical decision-making behavior should be administrated and guided by government,from the following seven aspects,so as to avoid "scientism" or " commercial alienation" phenomenon:national guidelines and standards development,academic standardization,expertise offering,medical training with human factors as well as legal punishment,medical knowledge accessibility,reimbursement restriction,and application of artificial intelligence.
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Objective To analyze the clinical characteristics for hypertensive attack during operation and clinical experience of preoperative evaluation and preparation in patients with pheochromocytoma and paraganglioma(PHEO/PGL).Methods A total 219 PHEO/PGL cases from September 2016 to September 2018 were retrospectively reviewed.It included 99 males and 120 females,aged 13 to 76 (average 47) years old.The mean diameter of tumor was 5.3 cm (1.5-18.0 cm).140 cases were unilateral PHEO,6 cases were bilateral PHEO,68 cases were PGL(jugular,mediaphragm,heart,retroperitoneum,pelvic and bladder) and 5 cases were PHEO combined with PGL.Preoperative highest systolic blood pressure (SBP)was 240 mmHg(1 mmHg-0.133 kPa) and highest diastolic blood pressure (DBP) was 160 mmHg.20 cases were occult PHEO without hypertension.217 cases accepted preoperative preparation of alpha-blocker [phenoxy-benzamine,dosage ranging from 5 mg Q12h to 40 mg Q8h,maximum dosage not exceeding 1 mg/(kg· 24 h)].2 cases did not accept preoperative preparation.All cases accepted open or endoscope surgery.The patients were divided into 2 groups depending on the presence or absence of hypertensive attack at the time of surgery.Patient demographic characteristics and preoperative evaluations were assessed for their prognostic relevance with respect to hypertensive attack.Results Histopathological results showed that all cases were PHEO or PGL,while 205 cases were benign,14 cases were malignant.Hypertensive attack were recorded in 112 cases(51％).The diameter of tumors in the hypertensive attack group were larger than that in the non-hypertensive attack group[(6.70 ± 2.95)cm vs.(3.95 ± 1.70) cm,P =0.005].There was no significant difference between the two groups among age [(51.0 ± 10.8) years vs.(38.5 ± 17.6) years,P =0.105],preoperative catecholamine level [norepinephrine (111.20 ± 41.49) μg/24 h vs.(419.15 ± 154.81) μg/24 h,P =0.075],time of use of alpha blockers [(53.0 ± 7.5) d vs.(38.0 ± 6.4) d,P =0.139],daily dosage of alpha blocker [(40.0 ±7.2)mg vs.(27.1 ± 1.8) mg,P =0.111] and blood pressure at diagnosis[(173.75 ± 26.69) mmHg vs.(155.0 ± 20.75) mmHg,P =0.139].Among 219 cases,2 case had emergency hemostasis after operation,1 case had catecholamine cardiomyopathy after operation for occult pheochromocytoma,and no perioperative death occurred.Conclusions Patients with large tumor tend to have hypertensive attack during operation so that should be better prepared.
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Objective To evaluate the expression profile of succinate dehydrogenase (SDH)B and SDHC in pheochromocytoma (PCC) and paraganglioma(PGL) (collectively abbreviated as PPGL), and their value in the early diagnosis of malignancy. Methods SDHB and SDHC immunohistochemistry were performed on 140 tumor specimens from 126 PPGL patients (PCC n＝62, PGL n＝61, PCC+PGL n＝3). Results (1) Germline mutation status of 67 patients were determined, of which, identifying 37(55.2%) patients with germline mutation: 2 (3.0%) SDHA, 18 ( 26. 9%) SDHB, 2 ( 3. 0%) SDHC, 5 ( 7. 5%) SDHD, 2 ( 3. 0%) VHL, 7 ( 10. 4%) RET, and 1(1.5%) NF1; and 30 (44.8%) individuals without known mutation. (2) Among 30 PPGLs from 27 patients with SDH-related (SDHx) mutations, 96.7%(29/30) stained negative for SDHB, 76.7%(23/30) stained negative for SDHC, while only 28.6%(14/49) and 18.4%(9/49) stained negative for SDHB and SDHC respectively in the 49 PPGLs without SDHx mutation (P<0.05). (3) The sensitivity of the SDH immunostaining in detecting the presence of germline SDHx mutation was 96.7%for SDHB and 76.7%for SDHC, while the specificity was 71.4%for SDHB and 81.6% for SDHC. ( 4 ) Among PPGLs without SDHB expression, 22. 9% were malignant. This percentage is significantly higher than that in PPGLs with preserved SDHB expression (3.8%, P<0.05). Conclusion SDHB and SDHC immunohistochemistry may serve as post-surgical screening tools to predict the presence of germline SDHx mutation in PPGLs. Negative SDHB expression calls for intense follow-up to rule out malignancy.
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Objective To study the incidence rate of prostate cancer detected in the specimen of radial cystoprostatectomy for bladder cancer and to evaluate its effect on the prognosis.Methods From June 2012 to June 2017,the clinical data of 132 patients with bladder cancer undergoing radical cystectomy (RCP) were analyzed retrospectively.The average age of 132 patients with bladder cancer was 61.2 years (37-89 years old).The serum of PSA of 89 cases out of 132 patients was examined before operation,21 cases 4 ng/ml ＜ tPSA ＜ 10 ng/ml,1 case tPSA 17 ng/ml and 67 cases tPSA ＜ 4 ng/ml.The pathology of bladder and prostate,the location and range of prostate cancer and Gleason score and the prognostic effect of prostate cancer was evaluated.Results The 132 patients with bladder cancer,116 cases (87.9％) were high grade urothelial carcinoma,8 cases (6.0％) were bladder carcinoma in situ,6 cases (4.5％) were low grade urothelial carcinoma,1 case was neuroendocrine bladder carcinoma and 1 case was signet ring cell carcinoma.The 21 cases of prostate cancer were combined with Gleason score,among which 3 + 2 score in 1 cases,3 +3 score in 17 cases,4 +3 and 3 +4 in 1 cases,and 4 +5 score in 1 cases.The lesions were unilateral in 14 cases and bilateral in 7 cases.The lesions were ＜0.5 ml in 3 cases,0.5-0.7 ml in 14 cases and 0.7-1.0 ml in 4 cases.The average age of 21 cases with prostate cancer was 67.5 years old (41-89 years).Of the 21 cases of prostate cancer,the serum tPSA was abnormal in 4 cases with an average of 8.8 ng/ml (4.2-17.0 ng/ml),the serum tPSA was normal in 12 cases with an average of 2.5 ng/ml (1.3-3.7 ng/ml),and the serum PSA in 5 cases was not detected before operation.Three cases of prostate cancer aged less than 60 years old with the detection rate of 9.6％ (3/31);18 cases were equal or older than 60 years old with the detection rate of 17.8％ (18/101).Multi parameter analysis showed that the incidence of prostate cancer increased with the age of the patients (OR =1.36,P =0.048).Followed up for 5 to 51 months,no PSA relapse was found and no patient receiving related treatment.Conclusions The detection rate of prostate cancer is very high in the specimen of radial cystoprostatectomy for bladder cancer.The clinical manifestation of the prostatic involvement is concealed.Radical resection of the prostate is necessary in radical resection of bladder cancer.
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Objective To discuss the diagnosis,perioperative treatment,cardiac function changing of pheochromocytoma/paraganglioma (PHEO/PGL) patients with catecholamine cardiomyopathy.Methods Fifteen PHEO/PGL patients with catecholamine cardiomyopathy were included in our hospital from Jan 2008 to Mar 2018.There were 8 males and 7 females with an average age of 32.8 years,ranging 13-64 years old.4 cases were found left PHEO.4 cases were found right PHEO and 3 cases were bilateral PHEO,including 2 cases of VHL.One case was jugular PGL.2 cases were lift PGL and 1 case was right PGL.The tumors diameter ranged from 2.3 to 7.2 cm.14 patients were diagnosed as PHEO/PGL with catecholamine cardiomyopathy with typical clinical manifestations of PHEO/PGL,such as headache,palpitation and perspiration.Their 24 hours of urine catecholamines showed an average of 24.87 μg/24 h in epinephrine and 551.70 μg/24 h in norepinephrine.Their average value of dopamine was 395.41 μg/24 h.Among 7 cases,the octreotide scan and Iodine-131-meta-iodobenzylguanidine (131 I-MIBG) s scan were positive in 6 and 1 case,respectively.Enhanced CT showed significantly heterogeneous enhancement tumors in adrenal or retroperitoneal area.Ischemia and necrosis area were found inside tumors.The blood flow of some tumors were extremely rich and irregular vascular network with a racemose distribution around the tumors could be observed.Echocardiography showed that the left ventricular ejection fraction (LVEF) ranged from 32％ to 54％,mean (42.0 ± 7.1) ％ during catecholamine cardiomyopathy.5 cases were mild abnormal,which the LVEF ranged from 45％ to 54％.9 cases were moderate abnormal,which the LVEF ranged from 30％ to 44％.Their catecholamine cardiomyopathy performance including left ventricular hypertrophy,myocardial echo enhancement and left ventricular enlargement.9 cases combined with acute left ventricular failure manifested as pulmonary edema and pink foamy phlegm.Sensitive antibiotics were given to suspected pulmonary infection patients.14 cases accepted regular alpha blockers,beta blockers and calcium antagonists treatment for 1 to 3 months and underwent surgery after a significant improvement in cardiac function.1 non-functional PHEO patient was lack of typical clinical and imaging changing.Both of her 24 hours of urine catecholamines and octreotide scan were negative.Echocardiography showed that LVEF was 73％ before operation.She was misdiagnosed as an adrenal non-functional adenoma.All patients underwent surgical treatment,including 13 laparoscopic surgery.One case switched to open surgery.2 PGL patients all accepted open surgery.Rusults All cases accepted complete resection of the tumors.1 case of nonfunctional PHEO had severe fluctuations in blood pressure during operation.Her BP were 190/130 to 80/50 mmHg (1 mmHg =0.133 kPa) and heart rate raised to 150 bpm.Catecholamine cardiomyopathy appeared in ICU ward after operation.Echocardiography showed that LVEF was 37％.The left ventricular enlargement and myocardial systolic function decreased.Fibrous bronchoscopy showed pink foamy phlegm in both sides of lungs.Chest X ray showed bilateral pulmonary edema which predominant in left side.The diagnosis was catecholamine cardiomyopathy of this patient.The LVEF was (55.9 ± 7.6)％ after treatment in 14 PHEO/ PGL patients with catecholamine cardiomyopathy,and there was statistically significant difference between before and after treatment (P =0.041).The LVEF was (66.1 ± 8.5) ％ postoperation,and there was statistically significant difference between postoperation and after treatment (P =0.013).The non-functional PHEO case occurred severe catecholamin cardiomyopathy after operation and cardiac function recovered after treatment.15 cases were followed up from 1 months to 10 years without recurrence.Conclusions PHEO/PGL patients with catecholamine cardiomyopathy should have adequate medication.The abnormal cardiac function of patients would be reversed after surgical treatment.Cardiac function failure would be recovered after active treatment.Non-functional pheochromocytoma patients were extremely dangerous.Adequate medication should be given to any suspected non-functional pheochromocytoma patients.
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Objective We aimed to investigate the overexpression of succinic dehydrogenase (SDH) B and MIB-1 in patients with pheochromocytoma/paraganglioma(PHEO/PGLs) and its significance for predicting the clinical malignant behavior.Methods From August 2008 to April 2016,the clinical characteristics of 93 patients with PHEO/PGLs were analyzed retrospectively.There were 57 males and 36 females,with an average of 34 years,ranging 8-73 years old.There were 68 cases of adrenal pheochromocytoma and 25 cases of paraganglioma.There were 79 cases with hypertension and 14 cases of adrenal accidental tumors.Sixty-six cases with typical hyper-catecholamine secretion symptoms and 27 cases with non-functional PHEO/PGL.Benign PHEO/PGLs were 77 cases and malignant 16 cases.The tumor was located on the left side in 39 cases,on the right side in 32 cases and multiple lesions in 22 cases.The diameter of the PHEO/PGL tumor was (6.8 ± 2.7) cm.The 24 h urine catecholamine was measured before operation,which showed epinephrine was (42.6 ± 5.1) μg/24 h,norepinephrine was (167.5 ± 13.5) μg/24h and dopamine was (246.4 ± 71.2)μg/24h.Six cases wihtout hereditary diseases of urinary system were selected as normal control group.SDHB,SDHAF2,SDHC,SDHD,VHL and RET gene mutations were detected in all patients.Immunohistochemical panel has been performed to detect the expression of SDHB,MIB-1,EPAS1,VEGF-1 receptor (VEGF-1 R),and chromain A (CgA) in 93 specimens of PHEO/PGL tissue.The positive granular cytoplasm staining ＞ 50％ was strongly positive (+ + +),11％ to 50％ was moderately positive (+ +),1％ to 10％ was weak positive (+) and the negative was compared with the known positive internal reference,that is,there was less than 1％ or no stain completely.Results SDHB,SDHAF2,SDHC,SDHD,VHL and RET gene mutations in 27 cases (29.5％).Nine patients with SDHB gene mutation (9.7％).RET proto-oncogene mutations in 8 cases (8.6％).3 cases had VHL mutation (3.2％).Immunohistochemical staining showed that MIB-1 positive expression was found in 7 of 9 patients with SDHB gene mutation.Six cases in the control group were negative for gene detection and MIB-1,EPAS1,CgA and VEGF-1R immunohistochemical results.EPAS1 showed moderately positive in patients with PHEO/PGL and strong positive in patients with malignant PHEO/PGL.In 9 cases with SDHM mutation,EPAS1 was noticed positive in seven cases,which showed the relationship with CgA,MIB-1 and VEGF-1R.Conclusions The SDHB gene mutation is usually shown as a paraganglioma focus outside the adrenal gland.And 9.8％ of the paragangliomas were associated with a mutation of the SDHB gene with an increase in malignant risk.The SDHB mutation caused over-expression of MIB-1 and the positive expression of EPAS1 and VEGF-1R in PHEO/PGL tissues,which was associated with invasion and metastasis of malignant PHEO/PGL.
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Objective To evaluate the diagnostic value of template-guided transperineal prostate biopsy (TTPB) by comparing biopsy-derived pathological results with findings from radical prostatectomy (RP) specimens.Methods From April 2013 to December 2015,patients who were diagnosed prostate cancer by transperineal template-guided 11-region prostate biopsy were enrolled in our study,and underwent laparoscopic RP.All whole-mount slices were reconstructed via a three-dimensional prostate model.Pathological features of the biopsy and RP specimens were compared.Detection rate of index lesions,overall sensitivity and specificity of TTPB,Gleason scores (GSs) in comparisons of biopsy and RP specimens were analyzed.Results One hundred and three patients were enrolled in our study,and the mean age was (65 ± 6)years.The median serum PSA was 11.7 ng/ml(IQR 7.2-19.1 ng/ml).The Gleason score ranged from 6 to 9.The clinical stage was T1c-T3a and the median prostate volume was 33.0 ml(IQR 26.0-43.0 ml).Eighty-nine of the 103 index lesions (86.4％) were detected by biopsy.The median volume was 1.2 ml (IQR 0.5-3.3 ml) and the mean maximum tumor length was (0.6 ± 0.4)cm.The overall sensitivity and specificity of the transperineal prostate biopsies were 53.3％ and 94.2％,respectively.RP-derived GSs were unchanged,upgraded and downgraded relative to the corresponding biopsy-derived GSs in 75 (72.8％),24 (23.3％) and 4 (3.9％) patients,respectively.Conclusions Stematic transperineal template-guided prostate biopsy could detect most of the index lesions.This biopsy approach was less able to determine tumour focal positioning and could only serve as a reference for guiding focal therapy.
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Cushing syndrome (CS) is a series of clinical symptoms and signs caused by long-term exposure to abnormally high levels of glucocorticoids.It is divided into two types of adrenocorticotropic hormone(ACTH) dependent and ACTH-independent CS.There are great differences in the target gland treatment of different causes of the disease, but the basic principle is to make a clear diagnosis.It is very important to treat primary lesions for ACTH-dependent CS.The adrenal gland will be resected when the treatment of primary lesions is not satisfied or the diagnosis is not clear.Adrenal sparing surgery is recommended for the definitive diagnosis adenomas of CS or subclinical CS.There is a lot of controversy about the treatment of ACTH-independent adrenal gland hyperplasia and primary pigmented nodular adrenal gland, and the individualized treatment scheme has been recognized.
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Objective To assess the long-term outcome of unilateral adrenaletomy in patients with adrenocorticotropic hormone independent macronodular adrenal hyperplasia (AIMAH).Methods The data from 82 cases of AIMAH were reviewed and summarized including clinical manifestations, endocrinological data, imaging findings and postoperative follow-up.Fouty-nine males and thirty-three females with a mean age of fifty years composed our series.Among the 82 cases, 41 demonstrated Cushing syndrome (CS), 74 presented with hypertension, 38 manifested diabetes mellitus, 35 complicated of osteoporosis and 11 of them with bone fracture, 39 complained of edema.Laboratory tests showed low ACTH plasma levels (＜ 2.2 pmol/L) in 62 of 79 cases.High level of 24-hour urinay free cortisol excretion(＞ 284.2nmol/L) was found in 67 of 79 cases.Elevated serum cortisol with loss of the circadian rhythm was presented in 55 of 60 cases.Failed to suppress cortisol secretion was observed in 61 of 63 conducted with low-dose dexamethasone suppression tests and in 47 of 53 implemented with high-dose dexamethasone suppression tests.Bilateral massively enlarged multinodular adrenal glands were found in all cases with CT or MR imaging.Unilateral adrenalectomy was performed in the larger side of adrenal gland in all 82 cases.All adrenalectomies were carried out including 47 in right sides and 35 in left sides, with 77 by retroperitoneoscopic approach and 5 by open retroperitoneal approach.Results Histopathological examination confirmed nodular hyperplasia of the adrenal cortex for all specimens.After a mean duration of 48.5 months, 80 of 82 patients were available for follow-up.Most clinical symptoms resolved within 6 months after operation.Cushingoid features disappeared in 58.5％ (24/41)of patients who initially presented with typical signs of Cushing Syndrome.Weight loss was seen in 56.3％ (45/80).Improvement of hypertension and diabetes was observed in 63.5％ (47/74) and 76.3％ (29/38) respectively.All the eyelids swelling and edema of the limbs subsided within 3 months.In long-term follow-up (more than 6 months), 82.9％ (63/76) had clinical and biochemical recurrence within a mean time of 14.6 months and 46.0％ (29/63) received contralateral adrenal surgery.Two patients died, one died from heart attack and another one died from pulmonary infection, 2 years and 7 years after unilateral adrenalectomy, respectively.Conclusions Unilateral adrenalectomy just has transient efficiency for AIMAH.Most patients will experience clinical and biochemical recurrence for a long period,and have to receive another operation for the contralateral hyperplastic adrenal gland.
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Objective To discuss the surgical treatment of primary pigmented nodular adrenocortical disease(PPNAD).Methods twenty-four cases of PPNAD were treated in our hospital from January 2005 to December 2017.Clinical data of these patients were reviewed.It included 8 males and 16 females with a mean age of 23 years old (range 14 to 58).23 cases presented with typical symptoms of Cushing syndrome, 1 case presented with hypertension.Eight cases could be diagnosed with Carney complex.All cases were confirmed as ACTH-independent Cushing syndrome.Adrenal imaging showed bilateral multiple nodules in 11 cases, unilateral multiple nodules in 4 cases, unilateral single mass or nodule in 3 cases, normal adrenals in 6 cases.Results All of the 24 cases received laparoscope unilateral adrenalectomy or laparoscope unilateral mass resection.After the operation, 8 cases underwent secondary operation because of symptom recurrence and the elevated 24-hour urinary free cortisol.Among them, 5 cases received contralateral subtotal adrenalectomy, 3 cases received contralateral total adrenalectomy.Seven cases with a slightly elevated 24-hour urinary free cortisol but a good recovery of Cushing symptoms were followed-up.Nine cases recovered well after the first operation and they didn't undergo secondary surgical treatment, but 1 of the 9 cases needed glucocorticoid replacement.Conclusions Bilateral adrenalectomy followed with long-term glucocorticoid replacement is the standard treatment of PPNAD.Unilateral adrenalectomy or subtotal adrenalectomy may be suitable for elected patients, but appropriate criteria need to be explored.
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Objective To investigate the surgical treatment of severe ectopic adrenocorticotrophic hormone(ACTH) syndrome.Methods The clinical data of 12 cases of severe ecotopic ACTH syndrome from January 1996 to December 2016 were retrospectively analyzed.The cases include 7 males and 5 females with a mean age 38 years(range 11 to 64 years).12 cases demonstrated typical Cushing syndrome(CS),accompanied by hypertension, diabetes, hypokalemia and severe osteoporosis.9 cases were complicated with thoracolumbar compression fractures.8 cases presented with pulmonary infection and fever during operation.7 cases had cardiac dysfunction.Laboratory tests showed elevated serum cortisol(695.0 ～ 1 661.5 nmol/L,mean 1 055.7 nmol/L), high urinary free cortisol excretion (807.3 ～ 28 240.0 nmol/24 h, mean 5 270.5 nmol/24h)and high ACTH plasma levels(16.5 ～ 273.9 pmol/L, mean 80.4 pmol/L).Source of ectopic ATCH were not identified and CT showed bilateral enlargement of adrenal in 12 patients.Results We performed emergency bilateral or unilateral adrenalectomy in 12 cases.Among them, one-stage bilateral adrenalectomy were given to 6 cases, staged bilateral adrenalectomy was performed in 3 cases, and unilateral adrenalectomy were given to 3 cases.The patients were treated with hormone replacement therapy after bilateral adrenalectomy.The excised adrenal gland showed diffuse thickening and multiple nodular.Pathological diagnosis were adrenal cortical hyperplasia.They have been followed up for 1 to 8years(median 2.5 years), 9 cases survived, 2 cases died of diabetes and severe pulmonary infection, and 1 case was lost to follow-up.Conclusions Severe ectopic ACTH syndrome is difficult to treat.Emergency adrenalectomy is effective for the management of severe ectopic ACTH syndrome especially for those patients with severe Cushing syndrome but primary tumor can not be located.
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Objective To discuss adrenalectomy effects on biochemical and metabolic impairment for patients with subclinical Cushing syndrome (SCS) due to an adrenal incidentaloma (AI) compared with conservative management.Methods Data from 87 patients with SCS due to AI in Peking Union Medical College Hospital between September 2011 and January 2016 were reviewed.Forty-eight patients underwent laparoscopic adrenalectomy (operative group), whereas 39 were managed conservatively (control group).No significant differences were found at baseline between the two groups concerning all the examined parameters, including age [(51.8 ± 10.2) years vs.(53.2 ± 12.1)years], male/female ratio (18/30 vs.20/19), size of adrenal mass [(3.01 ± 0.84) cm vs.(2.99 ± 1.01) cm], body mass index [(27.34 ±3.84) kg/m2 vs.(26.98 ± 3.99) kg/m2], adrenocorticotropic hormone (ACTH) [(2.01 ± 0.40) pmol/L vs.(1.96 ±0.42) pmol/L] and daily urinary free cortisol levels[(75.80 ± 39.71) mg vs.(71.06 ±31.35) mg], responsiveness to 1 mg of dexamethasone, arterial blood pressure, hypertensive patients (77.08％ vs.79.49％), glucometabolic control parameters, diabetic or impaired glucose tolerance patients (35.42％ vs.33.33％), lipid profile, dyslipidemia patients (70.83％ vs.71.79％).Results The duration of follow-up was 9-54 months in operative group, and 5-57 months in control group,respectively.In the operative group, laboratory corticosteroid parameters normalized in all patients but not in the control group.In the operative group, blood pressure of hypertensive patients improved or normalized (22 of 48).On the contrary, in the control group, cure or improvement was not achieved among the patients with hypertension, whereas worse condition was observed in 5 patients (P =0.004).No significant difference was found in glycemic control and blood lipid change between the two groups.However, a decrease in triglyceridaemia and HbA1c was found in operative group compared with the control group (P =0.011 and P =0.017, respectively).Substitutive corticosteroid treatment was administered in 3 patients due to postoperative adrenal insufficiency during hospital stay, and the duration of treatment was 9 weeks, 10 weeks and 12 weeks, respectively.Conclusion Laparoscopic adrenalectomy could be performed for patients with SCS due to AI.
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Objective To investigate the operative indication,therapeutic effects and feasibility of laparoscopic bilateral cortical-sparing adrenalectomy for pheochromocytoma.Methods The clinical data of 9 cases of bilateral pheochromocytoma from Jan.2011 to Dec.2016 were retrospectively analyzed.The cases included 7 males and 2 females with a mean age of 40 years old,ranging from 22 to 58.CT showed all the 9 cases had bilateral adrenal tumors.Results All patients accepted laparoscopic bilateral cortical-sparing adrenalectomy for pheochromocytoma.All survived and had been followed up for 4 months to 6 years (median 3.2 years).All cases kept normal adrenal function and avoid long-term corticosteroid dependence.Conclusions Bilateral pheochromocytoma is rare and difficult to treat.Adrenal function protection under laparoscopic bilateral cortical-sparing adrenalectomy for pheochromocytoma is safe and effective for patients.This opertation can both completely resect bilateral adrenal tumors and avoid long-term corticosteroid dependence.
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Objective: Tuberous sclerosis complex (TSC) is a multisystem genetic disorder caused by mutations in the TSC1 and TSC2 genes, but the molecular events contributing to TSC are not well understood.However, little is known about the role of microRNAs in TSC.To explore the microRNA differential expression profile between tuberous sclerosis complex cell line TSC2-/-MEFs and normal type cell line TSC2+/+ MEFs, and to provide new clues to study the mechanism of microRNA function in tuberous sclerosis complex.Methods: TSC2-/-MEFs and TSC2+/+ MEFs cell lines were cultured in vitro, each with three samples chosen as the experimental group and the control group respectively.Total RNA was isolated using TRizol and purified with RNeasy mini kit according to manufacturer''s instructions.RNA quality and quantity were measured by using nanodrop spectrophotometer and RNA integrity was determined by gel electrophoresis.Total RNAs were extracted by TRizol, followed by RNA quantification and quality control.MicroRNA profiles were analyzed by microarray and the threshold value used to screen up-regulated more than 2-fold change or down-regulated less than 0.5-fold change compared with controls.Real-time PCR was used to validate the reliability of microarray.Cell counting kit-8 (CCK-8) assay was performed to evaluate the proliferation.Results: Fourteen microRNAs, including miR-18a-5p, miR-376c-3p, miR-136-5p, miR-467c-5p, miR-467b-5p, miR-5104, miR-3098-3p, miR-30a-3p, miR-302b-3p, miR-18a-3p, miR-19b-1-5p, miR-19a-5p, miR-20a-5p, miR-155-5p, were up-regulated, while twenty-six microRNAs, including miR-200b-3p, miR-450a-1-3p, miR-542-5p, miR-199b-5p, miR-10a-5p, miR-466c-5p, miR-450a-5p, miR-450b-5p, miR-542-3p, miR-351-5p, miR-322-3p, miR-199a-3p, miR-335-5p, miR-10b-5p, miR-351-3p, miR-155-3p, miR-497a-5p, miR-503-5p, miR-148a-3p, miR-1843a-5p, miR-199a-5p, miR-490-5p, miR-450a-2-3p, miR-322-5p, miR-214-3p, miR-450b-3p, were down-regulated in tuberous sclerosis complex cell line TSC2-/-MEFs compared with normal type cell line TSC2+/+ MEFs (P<0.05).Real-time PCR confirmed the expressions of miR-136-5p, miR-30a-3p, miR-302b-3p, miR-10b-5p, miR-148a-3p, miR-199a-5p consistent with the microarray data (P<0.05).Furthermore, the overexpression of miR-199a-5p significantly inhibited cell proli-feration (P<0.05).Conclusion: There are differences in the expression of miRNA between the tube-rous sclerosis complex cell line TSC2-/-MEFs and normal cell line TSC2+/+ MEFs.MiRNA-199a-5p plays an important role in tuberous sclerosis complex, which may be developed as an important molecular target for the treatment of tuberous sclerosis complex.