[Low power seven-step two-lobe holmium laser enucleation of the prostate technique for surgical treatment of benign prostatic hyperplasia].

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.

[Application of machine learning models in predicting early stone-free rate after flexible ureteroscopic lithotripsy for renal stones].

OBJECTIVE: To establish predictive models based on random forest and XGBoost machine learning algorithm and to investigate their value in predicting early stone-free rate (SFR) after flexible ureteroscopic lithotripsy (fURL) in patients with renal stones. METHODS: The clinical data of 201 patients with renal stones who underwent fURL were retrospectively investigated. According to the stone-free standard, the patients were divided into stone-free group (SF group) and stone-residual group (SR group). We compared a number of factors including patient age, body mass index (BMI), stone number, stone volume, stone density and hydronephrosis between the two groups. For low calyceal calculi, renal anatomic parameters including infundibular angle (IPA), infundibular width (IW), infundibular length (IL) and pelvic calyceal height (PCH), would be measured. We brought above potential predictive factors into random forest and XGBoost machine learning algorithm respectively to develop two predictive models. The receiver operating characteristic curve (ROC curve) was established in order to test the predictive ability of the model. Clinical data of 71 patients were collected prospectively to validate the predictive models externally. RESULTS: In this study, 201 fURL operations were successfully completed. The one-phase early SFR was 61.2%. We built two predictive models based on random forest and XGBoost machine learning algorithm. The predictive variables' importance scores were obtained. The area under the ROC curve (AUROC) of the two predictive models for early stone clearance status prediction was 0.77. In the study, 71 test samples were used for external validation. The results showed that the total predictive accuracy, predictive specificity and predictive sensitivity of the random forest and XGBoost models were 75.7%, 82.6%, 60.0%, and 81.4%, 87.0%, 68.0%, respectively. The first four predictive variables in importance were stone volume, mean stone density, maximal stone density and BMI in both random forest and XGBoost predictive models. CONCLUSION: The predictive models based on random forest and XGBoost machine learning algorithm can predict postoperative early stone status after fURL for renal stones accurately, which will facilitate preoperative evaluation and clinical decision-making. Stone volume, mean stone density, maximal stone density and BMI may be the important predictive factors affecting early SFR after fURL for renal stones.

[Impact of diagnostic ureteroscopy and biopsy on radical nephroureterectomy of upper tract urothelial carcinoma].

OBJECTIVE: To investigate the impact of preoperative diagnostic ureteroscopy and biopsy (UB) on radical nephroureterectomy (RNU) and the prognosis of upper tract urothelial carcinoma (UTUC). METHODS: The clinical data of UTUC patients receiving RNU between Jan. 2007 and Dec. 2016 were retrospectively collected. The median follow up time was 40 months. The operation time and blood loss of RNU were compared between UB group and non-UB group. Subgroup analyses were conducted according to the time interval between UB and RNU, and surgery methods of lower ureter. The linear regression model was used to adjust for other common factors that impacted operation time. RESULTS: A total of 163 UTUC patients were included in the final analysis. For the lower ureter, open ureterectomies were performed in 91 patients (55.9%), while retroperitoneal laparoscopic ureterectomies were performed in 72 patients (44.1%). A total of 110 (67.5%) patients received preoperative UB. Compared with non-UB group, the average operation time of UB group was significantly longer [(252.5±79.8) min vs. (221.3±79.8) min, P=0.019], but no difference of blood loss was found (median, 50 mL vs. 50 mL, P=0.143). In subgroup analysis, the average operation time of RNU was significantly prolonged when RNU was performed after 1 week of UB (P=0.023). Meanwhile, the median blood loss of RNU increased significantly when it was done after 2 weeks of UB compared with non-UB group (100 mL vs. 50 mL, P=0.012). UB was also significantly prolonged the operation time of RNU in retroperitoneal laparoscopic ureterectomy group (P=0.012). In multivariable analysis, UB (P=0.049), ≥pT3 (P=0.039), pN+ (P=0.018) and ureterectomy method (P=0.005) were independent risk factors of prolonged operation time. The 3-year cancer specific survival (CSS) rate was 87.2% in our cohort. UB had no significant impact on cancer specific survival (P=0.435). CONCLUSION: UB was an independent risk factor of prolonged RNU time, but did not significantly influence cancer specific survival of upper tract urothelial carcinoma patients.

[Application of U-shaped convolutional neural network in auto segmentation and reconstruction of 3D prostate model in laparoscopic prostatectomy navigation].

OBJECTIVE: To investigate the efficacy of intraoperative cognitive navigation on laparoscopic radical prostatectomy using 3D prostatic models created by U-shaped convolutional neural network (U-net) and reconstructed through Medical Image Interaction Tool Kit (MITK) platform. METHODS: A total of 5 000 pieces of prostate cancer magnetic resonance (MR) imaging discovery sets with manual annotations were used to train a modified U-net, and a set of clinically demand-oriented, stable and efficient full convolutional neural network algorithm was constructed. The MR images were cropped and segmented automatically by using modified U-net, and the segmentation data were automatically reconstructed using MITK platform according to our own protocols. The modeling data were output as STL format, and the prostate models were simultaneously displayed on an android tablet during the operation to help achieving cognitive navigation. RESULTS: Based on original U-net architecture, we established a modified U-net from a 201-case MR imaging training set. The network performance was tested and compared with human segmentations and other segmentation networks by using one certain testing data set. Auto segmentation of multi-structures (such as prostate, prostate tumors, seminal vesicles, rectus, neurovascular bundles and dorsal venous complex) were successfully achieved. Secondary automatic 3D reconstruction had been carried out through MITK platform. During the surgery, 3D models of prostatic area were simultaneously displayed on an android tablet, and the cognitive navigation was successfully achieved. Intra-operation organ visualization demonstrated the structural relationships among the key structures in great detail and the degree of tumor invasion was visualized directly. CONCLUSION: The modified U-net was able to achieve automatic segmentations of important structures of prostate area. Secondary 3D model reconstruction and demonstration could provide intraoperative visualization of vital structures of prostate area, which could help achieve cognitive fusion navigation for surgeons. The application of these techniques could finally reduce positive surgical margin rates, and may improve the efficacy and oncological outcomes of laparoscopic prostatectomy.

[Ureteroscope can assist risk stratification in upper tract urothelial carcinoma].

OBJECTIVE: To analyze the efficiency of ureteroscope and biopsy in the diagnosis of tumor grade, muscle-invasiveness and multifocality in suspected upper tract urinary carcinoma (UTUC) patients in order to find out whether it can be used in the risk stratification of UTUC patients. METHODS: A retrospective study of 76 UTUC patients who underwent preoperative ureteroscope and/or biopsy and received radical nephroureterectomy in Peking University Third Hospital during January 2014 to December 2016 was undertaken. RESULTS: In this study, 76 patients were included. There were 31 males (40.8%), and 45 females (59.2%). The median age was 64.5 years (31-88), and 51 patients had the symptom of hematuresis. The tumor was located in renal pelvis in 39 patients, and in ureter in 37 patients. Post-operative pathology confirmed that all the 76 patients included in this study suffered from UTUC, of whom 21 (21.6%) were of low-grade, 51 (67.1%) were of high-grade, 4 (5.3%) were undetermined, and 47 (61.9%) patients were muscle-invasive, and 27 (35.5%) were not, and 2 (2.6%) were undetermined. Among the 50 patients, in whom the grade of the tumor could be diagnosed by biopsy, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value for low-grade tumor was 88.2%, 69.7%, 76.0%, 60.0% and 92.0%, respectively. Among the 27 patients, in whom the muscle-invasiveness could be diagnosed by biopsy, 5 patients were diagnosed with muscle-invasiveness, all confirmed by pathology after surgery and 22 patients were diagnosed with none muscle-invasiveness, turned out to be 50% muscle-invasive and 50% none-muscle invasive after surgery. The accuracy was 59.3%. The accuracy of ureteroscopic biopsy to diagnosis multifocality was 61.0%. On univariate analysis, biopsy grade was associated with postoperative pathology (P=0.001), while gender, age, side, body mass index (BMI), hematuresis, preoperative estimated glomerular filtration rate (eGFR), hydronephrosis, tumor size, location, multifocality and sessile were not associated with postoperative pathology grade. Biopsy grade (P=0.02), preoperative eGFR<90 mL/(min×1.73 m2)(P=0.025) and tumor located in pelvis (P=0.049) were associated with muscle invasiveness. Gender, age, side, BMI, hematuresis, hydronephrosis, tumor size, multifocality and sessile were not significantly associated with muscle invasiveness. CONCLUSION: Ureteroscope and biopsy can assist risk stratification in upper tract urothelial carcinoma patients.

[Perirenal cystic lymphangioma in an adult: a case report and literature review].

Lymphangioma is a rare, benign mesenchymal neoplasm, which is characterized by numerous intercommunicating cystic spaces containing lymphatic fluid. It is considered a congenital disease resulting from the obstruction of regional lymph drainage during the developmental period. Lymphangioma frequently occurs in the cervical neck and axilla, also in the retroperitoneum, mediastinum, mesentery, omentum, colon, and pelvis, rarely in the perirenal space. These tumors usually present in childhood, but infrequently, these also present in adults. Patients often complain of hematuria, flank pain, or abdominal pain. Complications of lymphangioma have been reported to include infection, ruputure, or hemorrhage. There are three types of lymphangioma commonly identified: capillary, cavernous, and cystic. Cystic type is the one commonly found intra-abdominally or retroperitoneally, and may be uniloculated or multiloculated. All these perirenal tumors have a very low incidence, make it difficult to diagnose. Differential diagnosis must be performed with the primary renal lymphoma, urinoma, polycystic kidney, teratoma, both benign and malignant tumors, etc. Endoscopic ultrasound guided fine needle aspiration is recommended in some literatures, which may help make diagnosis and further guide subsequent therapeutic strategy. Regarding treatment, surgical excision can be performed via either laparotomy or laparoscopy. And injection of sclerosants into lympahgioma has been described in the literature in nonsurgical candidates. The optimal definitive treatment is total surgical excision. Despite being rare, the tumor has an excellent prognosis. Here, we report a case of a 48-year-old woman with a left renal mass found in an abdominal ultrasonography during a health checkup. In the case presented, abdominal ultrasonography and magnetic resonance urography (MRU) revealed an approximately 11.3 cm×10.6 cm×12.8 cm multilocular cystic mass in the left perirenal space. There was no history of bowel or bladder complaint, either previous illness episodes. Full blood count and kidney function tests were within normal limits. Laparoscopic surgical removal of the cyst was accomplished without incident. A benign cystic perirenal lymphangioma was diagnosed on histology and confirmed with immunohistochemical stains. One month after the surgery the ureteral stent was removed. The patient was free of disease after a 3-month follow-up period. We report the case and discuss the management of perirenal lymphangiomatosis with a literature review.

IgE-regulated loss, not IgE-regulated synthesis, controls expression of FcepsilonRI in human basophils.

Expression of the high-affinity receptor on basophils and mast cells is modulated by immunoglobulin E (IgE) antibody. Recent studies have shown that modulation occurs through interaction of IgE with the receptor itself, but the mechanisms underlying this control are not understood. Taking both a theoretical and experimental approach, we examined several competing models that focus on whether there is IgE-regulated loss, IgE-regulated synthesis, or both regulated loss and synthesis of the Fc receptor for IgE (FcepsilonRI). We report that removing IgE from occupied FcepsilonRI resulted in an accelerated loss only in the unoccupied receptor, with no loss of occupied receptors and no loss of total receptors when all receptors were occupied. Together with previous studies, these results establish that there was IgE-regulated loss of receptors. An examination of synthetic rates of FcepsilonRIalpha using pulse-labeling with (35)S-methionine indicated no difference in synthetic rates in the presence or absence of IgE. Similarly, the presence or absence of IgE had no influence on the levels of mRNA for either alpha, beta, or gamma subunits of FcepsilonRI. Using model simulations, we found that regulated-synthesis models could be distinguished from regulated-loss/constant-synthesis models on the basis of the relationship between starting FcepsilonRI densities and changes in density after culture for 1 week in the absence of IgE. Experimental data from this type of study fit a regulated-loss model that did not include regulation of synthesis. Taken together, these results suggest that IgE regulates cell surface expression of FcepsilonRI only by regulating the rate that receptor is lost from the cell surface.

[Cloning of the sugar related biosynthesis gene cluster from Streptomyces tenebrarius H6].

Streptomyces tenebrarius H6 produces a complex of aminoglycoside antibiotics, such as apramycin, tobramycin and kanamycin B etc. To study the apramycin biosynthetic genes the genomic library from the Streptomyces tenebrarius H6 was established using E. coli/Streptomyces shuttle vector pKC505 by in vitro packing. The probability of finding a specific gene from the library composed of 3,000 colonies was over 99.9%. According to the highly conserved sequence of the genes involved in 6-deoxyhexose biosynthesis, primers were designed and 0.6 kb fragment homologous to strE gene was obtained by PCR. 30 positive clones were found from the genomic library of S. tenebrarius H6 with the 0.6 kb fragment as a probe. Overlapped regions were localized by Southern hybridization and putative sugar related biosynthetic gene cluster was mapped by restriction enzyme digestions. An ORF of dTDP-glucose-4,6-dehydratase gene consisted of 1,132 bp, designated as aprE, was obtained and submitted to GenBank under the accession number of AF306787. A DNA sequence highly homologous to strL coding dTDP-4-dehydrorhamnose reductase was found linked with aprE gene.

Disialoganglioside GD3 is selectively expressed by developing and mature human mast cells.

BACKGROUND: Disialoganglioside GD3 is expressed on the surface of selected cell types. Anti-GD3 mAb administered to human subjects with malignant melanoma produces signs and symptoms of immediate hypersensitivity reactions. OBJECTIVE: The expression of GD3 by human mast cells was assessed during mast cell development in vitro and in samples of lung and skin. METHODS: GD3 on tissue- and in vitro-derived mast cells was analyzed after double labeling of cells for tryptase (G3 mAb) or Kit (YB5.B8 mAb) and GD3 (R24 mAb). Glycolipids in extracts of fetal liver-derived mast cells were examined by using high-performance thin-layer chromatography. RESULTS: Flow cytometry showed that the percentage of GD3+ cells increased in parallel to Kit+ cells during the recombinant human stem cell factor-dependent development of fetal liver-derived mast cells. Double-labeling experiments showed that GD3+ cells were also surface Kit+ and granule tryptase positive, identifying them as mast cells in preparations of lung-, skin-, fetal liver-, and cord blood-derived cells. The major acidic glycolipid detected was NeuAcalpha2-8NeuAcalpha2-3Galbeta1-4Glcbeta1-1'Cer (GD3). Among peripheral blood leukocytes, only basophils and about 10% of the T cells were labeled with anti-GD3 mAb. Anti-GD3 mAb-conjugated magnetic beads were used to purify mast cells to greater than 90% purity from dispersed skin cells enriched to approximately 12% purity by means of density-dependent sedimentation but were less proficient for dispersed human lung mast cells, most likely because of other cell types that express GD3. CONCLUSION: GD3 is expressed on the surface of developing human mast cells in parallel to tryptase in secretory granules and, like Kit, can serve as a target for their enrichment by immunoaffinity techniques.

Immunohistochemical detection of human basophils in late-phase skin reactions.

BACKGROUND: Human basophils are difficult to detect with classic histochemical stains at sites of allergic inflammation. The 2D7 anti-basophil monoclonal antibody was used to identify basophils in skin during the late-phase response to a cutaneous allergen challenge. METHODS: The 2D7 monoclonal antibody was used on protease-digested sections of skin biopsy specimens obtained 6 and 24 hours after an allergen or buffer challenge. The skin chamber technique was used to compare buffer- and allergen-challenged sites at 6 hours, and intradermal injection of allergen was used to compare allergen-challenged sites at 6 and 24 hours. RESULTS: Dramatic increases in the numbers of 2D7+ cells and in tissue staining by 2D7 were observed 6 hours after allergen challenge compared with buffer challenge. Histamine levels in skin chamber fluid varied with 2D7+ cell concentrations. By 24 hours, 2D7+ cells and tissue staining appeared to diminish but were still detectable in the allergen-challenged sites. Basophils localized primarily in and around blood vessels, whereas mast cells remained mostly in the superficial dermis. Mast cells were 2D7- in both the allergen- and buffer-challenged skin. Metachromatic staining of 2D7+ basophils with toluidine blue was absent in these tissue sections. CONCLUSIONS: The 2D7 monoclonal antibody provides a more sensitive and precise marker than histochemical staining for human basophil involvement during the late-phase response to an allergen challenge. Basophil infiltration was observed at 6 hours only after allergen challenge and persisted at similar levels by 24 hours.

Effect of recombinant human IL-4 on tryptase, chymase, and Fc epsilon receptor type I expression in recombinant human stem cell factor-dependent fetal liver-derived human mast cells.

The effect of recombinant human IL-4 (rhIL-4) on the development of recombinant human stem cell factor-dependent fetal liver-derived mast cells was examined. RhIL-4 attenuates the number of mast cells that develop, preferentially affecting the MC(T) type of mast cell. Cellular levels of tryptase and chymase mRNA normalized to that of glyceraldehyde-3-phosphate dehydrogenase were not appreciably affected. Tryptase mRNA levels peaked at least 2 wk before tryptase protein and before chymase mRNA and protein, indicating that tryptase mRNA expression is an early marker of commitment to a mast cell lineage. In contrast, alpha-tryptase and beta-tryptase mRNA levels increased and decreased in parallel. The most dramatic effect of rhIL-4 was to induce expression of functional surface Fc epsilonRI. Expression was maximal by 21 days with 20 ng/ml of rhIL-4 and reached a plateau by 2 ng/ml of rhIL-4 at 4 wk. Fc epsilonRI+ cells increased modestly when myeloma IgE was added to the developing mast cells, but increased synergistically when both myeloma IgE and rhIL-4 were present together. Delayed addition of rhIL-4 progressively diminished Fc epsilonRI expression, as did withdrawal of rhIL-4 during the first 2 wk of culture. RhIL-4 selectively increased Fc epsilonRI alpha mRNA levels at least 10-fold. Mast cells developed in the presence of rhIL-4 released tryptase when exposed to anti-Fc epsilonRI alpha. In conclusion, induction of functional Fc epislonRI on recombinant human stem cell factor-dependent human fetal liver-derived mast cells by rhIL-4 harmonizes with the well-accepted ability of this cytokine to enhance IgE production by B cells.

Quantitation of tryptase, chymase, Fc epsilon RI alpha, and Fc epsilon RI gamma mRNAs in human mast cells and basophils by competitive reverse transcription-polymerase chain reaction.

Competitive reverse transcription-PCR assays developed for human tryptase, chymase, Fc epsilon RI alpha, and Fc epsilon RI gamma mRNA molecules were applied to the HMC-1 leukemic mast cell line, the KU812 leukemic basophil cell line, mast cells dispersed from lung and skin, and peripheral blood basophils. Relative amounts of alpha-tryptase and beta-tryptase mRNA were determined by analysis of BseAI digests of PCR products. Tryptase expression was highest in tissue-derived mast cells, lowest in basophils and KU812 cells, and intermediate in HMC-1 cells. beta-Tryptase mRNA predominated in HMC-1 and KU812 cells; mixtures of alpha- and beta-tryptase were found in tissue mast cells; and alpha-tryptase predominated in basophils. Chymase mRNA was more abundant in skin-derived (nearly all of the MCTC type) than lung-derived (variable amounts of MCTC and MCT cells) mast cells. Small amounts of chymase mRNA were detected in HMC-1 cells; none was found in basophils, in KU812 cells, or in the one preparation of 100% MCT cells derived from lung. Comparable amounts of Fc epsilon RI alpha and Fc epsilon RI gamma mRNA molecules were measured in basophils and tissue-derived mast cells, lesser amounts were detected in KU812 cells, and almost none was detected in HMC-1 cells. Thus, steady state levels of the granule and membrane resident molecules examined in our study are transcriptionally regulated in mast cells and basophils.

Differential regulation of human B-lymphocyte tumor necrosis factor-alpha (TNF-alpha) and lymphotoxin (TNF-beta) production by protein phosphatase 1 and 2A inhibitor.

Tumor necrosis factor (TNF) and lymphotoxin (LT; TNF-beta) are major cytokines produced by B lymphocytes. Stimulation by okadaic acid, a phosphatase 1 and 2A inhibitor, markedly increased TNF mRNA accumulation and cytokine production. On the other hand, the accumulation of LT mRNA was not affected by okadaic acid despite structural and functional similarities between TNF and LT. The increase in TNF mRNA accumulation was due to the stimulation of gene transcription and a marked stabilization of this mRNA. The binding activities of the transcription factors AP-1 and AP-2 and NF kappa B, which regulates TNF gene transcription, were also stimulated by okadaic acid. In addition, okadaic acid was shown to increase TNF production at the protein level. These results show the importance of protein phosphatases in the regulation of cytokine production in B cells, and further identifies differences in the regulation of TNF-alpha and LT production.