2012年 · 第125卷第21期

Multiple academic organizations,administrative authorities,and some commercial bodies in medicine have accepted the fact that simulation has become crucial and brought tremendous changes in surgical education and training.1 When integrated into surgical education and training system,simulation not only improves the quality of surgical service by upgrading surgeons' skills and decreasing time to the mastery of various critical techniques,but also secures the safety of patients。

Currently,the predominant therapy for urinary calculi is minimally invasive treatment,which could reduce injury to patients while enhancing the success rate,compared to traditional open surgery.Minimally invasive treatments in urinary system include extracorporeal shock wave lithotripsy (ESWL),percutaneous nephrostolithotomy (PCNL),ureteroscopic lithotripsy (URSL),laparoscopy,and so on.Despite the relative small injury,however,minimally invasive treatment is more expensive and has some potential risks.1,2 Therefore,small calculi that could be expulsed spontaneously and without clear surgical indications can be treated with conservative strategy.The medical expulsion therapy (MET) that is effective,safe,non-invasive,and suitable for outpatients is definitely an ideal option for patients who are eager to remove calculi but are only suffering symptomatic calculi in the upper urinary tract.It has become the focus for basic and clinical researches in recent decades。

Beginning in the early 1990s,laparoscopy has evolved to an established technique for the management of many urological diseases including difficult and advanced procedure.As we know,laparoscopy does require a set of skills much different from those of open surgery,among them are reduced depth perception,loss of haptic feedback,restrictive freedom of movement,and requirement of a video-eye-hand coordination.The learning curve for many laparoscopic procedures is steep and laparoscopic-skill acquisition is in fact more difficult than that for open surgery,which further validates the need for training。

Abstract：Background It remains a challenge to inhibit the local recurrence or distant metastasis of localized or locally advanced renal cell carcinoma (RCC) after surgical resection.We investigated the feasibility,safety and efficacy of immunotherapy using autologous tumor lysate (TL)-pulsed dendritic cells (DCs) and cytokine-induced killer (CIK) cells in patients with localized or locally advanced RCC.Methods From January 2001 to July 2009,we collected 137 patients that met the selection criteria and randomly divided them into three groups.After surgery,immunotherapy with TL-pulsed DCs-CIK cells (DC-CIK group) and interferon (IFN)-α (IFN-α group) was performed in 46 patients,respectively.The other 45 patients received no postoperative adjuvant therapy (the control group).The changes in the numbers of T lymphocyte subsets,including CD4+CD25high regulatory T cells (Treg),were determined before the operation and after immunotherapy.The overall survival was compared among the three groups.Results An increase of the CD4+/CD8+ ratio and a decrease of CD4+CD25high cells were observed after TL-pulsed DC-CIK cells or IFN-α immunotherapy.All patients tolerated the TL-pulsed DC-CIK cells immunotherapy very well,and side effects in the DC-CIK group were less than in the IFN-α group.The metastasis and recurrence rates were significantly decreased after TL-pulsed DC-CIK cells or IFN-α immunotherapy compared with the control group (P ＜0.01).The Log-rank test showed that the overall survival rates were significantly higher in the DC-CIK group and IFN-α group than that in the control group (P ＜0.01),but there was no difference between the DC-CIK group and IFN-α group (P ＞0.05).Conclusion Postoperative immunotherapy with TL-pulsed DC-CIK cells may prevent recurrence/metastasis and increase the overall survival rate after surgery in localized or locally advanced RCC。

Abstract：Background Detrusor overactivity (DO) is a known cause of lower urinary tract symptoms and occurs in 50％-75％ of benign prostate hyperplasia (BPH) patients.We sought to investigate the clinical and urodynamic factors that are associated with the presence of DO in Chinese BPH patients.Methods Two hundred and eighty-seven consecutive patients with clinical BPH were retrospectively evaluated in this study.Each patient underwent urodynamic evaluation and completed the International Prostate Symptom Score (IPSS)and Quality of Life (QoL) questionnaire.Patients with neurological symptoms or other diseases likely to affect detrusor functions were strictly excluded.The 184 BPH patients included in the study were divided into groups according to the presence of DO as shown in urodynamic tests.Univariate analysis of factors associated with the presence of DO were performed using Student's t-test and the Mann-Whitney test; multivariate analysis used stepwise Logistic regressions.The relationship between degree of bladder outlet obstruction (BOO) and DO was also investigated using a linear-by-linear association test.Results Of 184 BPH patients,DO was present in 76 (41.3％).On univariate analysis,patients with DO were older (P=0.000),and showed smaller maximal bladder capacity (MBC,P=0.000) and voided volume (P=0.000),higher maximal detrusor pressure (P=0.000) and projected isovolumetric pressure (PIP) (P=0.005),higher Abrams-Griffiths number (P=0.000) and degree of bladder outlet obstruction (P=0.000),higher IPSS (P=0.000) and irritative IPSS subscores (P=0.000).Stepwise Logistic regression analysis showed that PIP (OR=1.012,95％ CI1.002-1.023,P=0.019),age (OR=1.030,95％ CI 1.005-1.067,P=0.059),and MBC (OR=0.993,95％ CI 0.990-0.996,P=0.000)were independent risk factors for DO in BPH patients.Linear-by-linear association tests indicated a positive linear association between DO and severity of BOO,with incidence of DO increasing with BOO grade (P=0.000).Conclusions In Chinese BPH patients,PIP,MBC,and age were independent factors affecting the presence of DO.DO incidence continuously increases with the degree of BOO。

Abstract：Background Delayed graft function (DGF) is common in kidney transplants from organ donation after cardiac death (DCD) donors.It is associated with various factors.Determination of center-specific risk factors may help to reduce the incidence of DGF and improve the transplantation results.The aim of this study is to define risk factors of DGF after renal transplantation.Methods From March 2010 to June 2012,56 cases of recipients who received DCD kidneys were selected.The subjects were divided into two groups:immediate graft function (IGF) and DGF groups.Transplantation factors of donors and recipients as well as early post-transplant results of recipients were compared between the two groups.Results On univariate analysis,preoperative dialysis time of recipients (P＜0.001),type of dialysis (P=0.039),human leucocyte antigen (HLA) mismatch sites (P＜0.001),the cause of brain death (P=0.027),body mass index (BMI) of donors (P＜0.001),preoperative infection (P=0.002),preoperative serum creatinine of donors (P ＜0.001),norepinephrine used in donors (P ＜0.001),cardiopulmonary resuscitation (CPR) of donors (P ＜0.001),warm ischemia time (WIT) (P＜0.001) and cold ischemia time (CIT) (P＜0.001) showed significant differences.Recipients who experienced DGF had a longer hospital stay,and higher level of postoperative serum creatinine.Conclusion Multiple risk factors are associated with DGF,which had deleterious effects on the early post-transplant period。

Abstract：Background Acute rejection remains an important cause of renal allograft dysfunction and the need for accurate diagnosis is essential to successfully treat transplant recipients.The purpose of this study was to determine the costimulatory molecules OX40 and OX40L messenger RNA (mRNA) levels in peripheral blood mononuclear cells (PBMCs) to predict acute renal transplant rejection.Methods The whole blood samples from 20 recipients with biopsy-confirmed acute rejection (rejection group),20 recipients with stable graft function and normal biopsy results (stable group) after kidney transplantation,and 20 healthy volunteers (control group) were collected.The mRNA levels of OX40 and OX40L were analyzed with TaqMan real-time reverse transcriptase polymerase chain reaction (RT-PCR).The association of OX40 and OX40L mRNA levels with disease severity was investigated.Results There was no significant difference of OX40,OX40L mRNA levels in PBMCs between the stable group and control group (P＞0.05).The levels of OX40 and OX40L mRNA were significantly higher in the rejection group than in the control group (P＜0.01 and P＜0.05,respectively).Non-significantly higher OX40L mRNA and significantly higher OX40 mRNA in PBMCs were observed in subjects in the rejection group compared with the stable group (P ＞0.05 and P ＜0.01,respectively).Receiver operating characteristic (ROC) curve analysis demonstrated that OX40 mRNA levels could discriminate recipients who subsequently suffered acute allograft rejection (area under the curve,0.908).OX40 and OX40L mRNA levels did not significantly correlate with serum creatinine levels in the rejection group (P ＞0.05).Levels of OX40 mRNA after anti-rejection therapy were lower than those at the time of protocol biopsy in the rejection group (P＜0.05).Conclusion Our data suggest that measurement of OX40 mRNA levels after transplant might offer a noninvasive means for recognizing recipients at risk of acute renal allograft rejection。

Abstract：Background Open pyeloplasty has been historically described as the gold standard for the surgical treatment of ureteropelvic junction obstruction (UPJO),even if new techniques have recently gained a prominent role in this field.Laparoscopic pyeloplasty (LP) is not widely prevelant because of the technically challenging nature and it represents the gold standard for UPJO only in expert hands.To overcome some difficulties and technical challenges encountered during pure laparoscopic pyeloplasty,we designed a set of new instruments and assessed them using porcine model.Methods According to the ideas from the surgeons,our medical engineer designed three new instruments,including the right angle laparoscopy scissors,the petal-shape ureter dilator and the guide tube.Four experienced laparoscopic experts were involved in a no survival porcine study to assess the help of these new instruments.Four experiments were conducted on live pigs that weighed 22 to 25 kg at the same time.After general anesthesia was administered,transperitoneal ureteroureterostomy was performed using standard laparoscopic instruments,including placing the double J stent anterograde.Then,the opposite lateral was done by the same surgeon plus these new devices for side-by-side comparative analysis.All experts were interviewed to assess these new instruments by the questionnaire based on the visual analog scale (VAS) from 1 (none) to 10 (very much).Results The procedures were all technically successful.The right angle laparoscopy scissors and the guide tube were accepted by all participants and the Help Score were 6.75 and 4.25 respectively,at the same time the New Difficulty Score 1.25 and 1.75.However,the petal-shape ureter dilator got 1.5 Help Score and 6.5 New Difficulty Score.These surgeons made a negative comment and one of surgeons recommended the stone basket was more suitable.Conclusion The right angle laparoscopy scissors and the guide tube may be helpful to minimize some difficulties in pure laparoscopic pyeloplasty。

Abstract：Background Recently,the number of patients with prostate cancer who needed to be treated with radical prostatectomy increased rapidly in China.There is still a difference between clinical staging and the post-operative final pathologic staging; hence,an excellent tool for accurately predicting the pathologic stages of prostate cancer is needed urgently in clinical practice.The Partin tables are the most popular and widely used tool for predicting the pathologic stages of prostate cancer because of its high accuracy and ease of implementation.The aim of this study was to externally validate the accuracy of the three versions of the Partin tables in predicting the post-operative pathologic stages in Chinese patients with prostate cancer.Methods We retrospectively analyzed the data from 203 patients with prostate cancer who underwent radical prostatectomies between June 2000 and May 2012.The accuracies of the three versions of the Partin tables in predicting the post-operative pathologic stages in Chinese patients with prostate cancer were evaluated using the area under the receiver operating characteristic curve (AUC).Results Using the 1997,2001,and 2007 Partin tables for predicting the current cases,the AUC of organ confinement (OC) was 0.877,0.788,and 0.726; the AUC of extracapsular extension (ECE) was 0.525,0.615,and 0.608; the AUC of seminal vesicle invasion (SVI) was 0.875,0.649,and 0.820; and the AUC of pelvic lymph node invasion (LNI) was 0.808,0.758,and 0.735 respectively.Conclusions The accuracies of the three versions of Partin tables in predicting OC,SVI,and LNI were good,especially the 2001 Partin table for SVI.In contrast,the accuracy of the three versions of the Partin tables in predicting ECE was fair.The 1997 Partin table was much better than the 2007 table in predicting OC,and the 2001 table in predicting SVI.The 2007 Partin table did not show any advantages。

Abstract：Background A disintegrin and metalloprotease 9 (ADAM9) is a membrane-anchored enzyme which is considered to be involved in some diseases including tumor.However,the role of ADAM9 in castration resistant prostate cancer (CRPC) is not clear.This study aimed to explore the different expressions on protein and messenger RNA (mRNA) level of ADAM9 between hormonal sensitive prostate cancer (HSPC) and CRPC tissue,and find the correlation with prognosis.Methods Clinicopathologic characteristics of 106 HSPC and 76 CRPC cases were collected.The ADAM9 expressions were analyzed using immunohistochemistry.ADAM9 mRNA of 32 additional cases (16 HSPC and 16 CRPC patients)were analyzed via quantitative real-time polymerase chain reaction (RT-PCR).The prediction values of variables for overall survival (OS) of CRPC patients were analyzed using Cox regression.Results ADAM9 protein expression was significantly downregulated in CRPC compared with HSPC tissue (31.6％ vs.81.1％,P＜0.001).The relativity transcription level of ADAM9 mRNA was 0.45 for CRPC tissue and 1.0 for HSPC tissue (P=0.002).In the CRPC group,patients with low ADAM9 protein expression were significantly associated with shorter OS than patients with high expression (38.6 months vs.57.8 months,hazard rate (HR)=2.638,P=0.023).Conclusion ADAM9 expression was low in CRPC,correlated with poor prognosis and might be involved in the succession from HSPC to CRPC by various functions。

Abstract：Background Late onset hypogonadism negatively impacts on men's psychological well-being.This study was conducted to examine the interrelationship among symptoms of testosterone deficiency,psychological well-being,and quality of life.Methods Eligible subjects were randomized into active treatment and control groups,and were asked to complete the following questionnaires at baseline and month 6:aging male's symptoms (AMS) rating scale,hospital anxiety and depression scale (HADS),perceived stress scale (PSS) and the short form health survey-12 (SF-12).In this study,men were treated and monitored for 6 months with oral testosterone undecanoate (TU) capsules or vitamin E/C capsules in a single-blinded fashion.All in the active treatment group were administered a total of 120-160 mg TU orally on a daily basis.Total and free T levels between baseline and month 6 were compared.Results One hundred and sixty eligible subjects were recruited and followed up.In the active treatment group,total serum testosterone concentrations before and after intervention were (7.98±0.73) nmol/L and (13.7±1.18) nmol/L.The mean HADS anxiety subscale scores for the subjects at baseline and at month 6 were 3.47±0.4 and 1.72±0.2,respectively (t=1.526,P＜0.05).Additionally,the mean HADS depression subscale scores were 4.91±0.6 and 2.39±0.3,respectively (t=3.466,P＜0.05).The mean scores on PSS for the subjects at baseline and at month 6 were 12.88±2.1 and 9.83±1.7,respectively (t=4.009,P＜0.05).Significantly improved SF-12 could be observed (t=1.433 and 1.118,respectively; both P＜0.05).No significant changes were observed in the control group at month 6.Conclusion Androgen replacement not only improves androgen deficiency associated symptoms,but also enhances comprehensive improvement in psychological issues.(No.ChiCTR-TRC-11001811)

Abstract：Background Transurethral resection of prostate (TURP) has been considered as the standard treatment for benign prostatic hyperplasia (BPH).However,issues that have not yet been overcome for TURP include bleeding and absorption of irrigation fluid.Thus,novel improvement of the surgery is necessary.This study aimed to evaluate the efficacy and safety of bipolar plasma vaporization of the prostate (BPVP) with "button-type" electrode against standard TURP for BPH.Methods From January 2009 to January 2012,30 patients who scheduled for surgical treatment of BPH surgical treatment were enrolled in the trial with provided consent for the study.Patients were prospectively randomized 1∶1 to undergo either BPVP or TURP.Participants were blinded to the randomization scheme.All cases were assessed preoperatively and followed at 1,3,and 6 months postoperatively by indwelling catheter time,blood loss,hospital stays,International Prostate Symptom Score (IPSS),quality of life (QOL),and Qmax.Results BPVP was significantly superior to TURP in terms of indwelling catheter time ((4.1±4.1) days vs.(6.8±6.8)days,P=0.000),blood loss ((64.7±103.8) ml vs.(254.7±325.4) ml,P=0.040),hospital stay ((8.7±1.0) days vs.(11.7±1.5)days,P=0.000),IPSS ((4.2±8.0) vs.(9.3±3.7),P=0.049),QOL ((1.5±0.8) vs.(2.6±1.4),P=0.027),Qmax ((16.3±5.7) ml/s vs.(12.5±3.1) ml/s,P=0.038),hemoglobin ((130.7±9.4) g/L vs.((122.1±11.9) g/L,P=0.047),Na+ level ((138.6±2.1)mmol/L vs.((137.2±2.0) mmol/L,P=0.046) and operation time ((39.0±15.5) minutes vs.((69.3±24.8) minutes,,P=0.004).And there were no statistical differences between BPVP group and TURP group in preoperatively assessment:patient's age ((70.9±7.1) years vs.(71.9±6.1) years,P=0.736),IPSS ((24.6±4.7) vs.(27.3±5.9),P=0.100),QOL ((5.1±0.8) vs.(5.1±1.0),P=0.940),Qmax ((4.4±2.7) ml/s vs.(5.3±2.6) ml/s,P=0.314),hemoglobin ((137.4±8.7) g/L vs.(139.2±10.4)g/L,P=0.623),Na+ level ((140.5±1.8) mmol/L vs.(141.3±1.4) mmol/L,P=0.192) and prostate volume ((59.0±17.4) ml vs.(70.1±28.8) ml,P=0.276).Conclusions Compared with TURP,BPVP with "button-type" electrode shows superior efficacy and safety.Therefore,BPVP with "button-type" electrode represents a valuable endoscopic treatment alternative for BPH patients。

Abstract：Background Laparoendoscopic single-site surgery radical prostatectomy (LESS-RP) is a challenging urological procedure and needs to be further evaluated.This study was undertaken to illustrate the safety and initial results of pure LESS-RP with conventional available instruments.Methods A prospective clinical database was established in September 2010 to assess the outcome following the introduction of LESS-RP at our institution.By June 2012,six procedures had been performed.The mean patient age was 74.7 (74.0-76.0) years.The mean body mass index (BMI) was 23.8 (19.5-32.2) kg/m2.The LESS-RP was preformed through an extra-peritoneal approach using single port access with QudaPort,0° lens 5 mm flexible tip video-laparoscope and available conventional laparoscopic instruments.Parameters assessed were operative time,estimated blood loss,intra-operative complications,drainage time,postoperative pain score (visual analogue pain scale (VAPS),0-10),pathological results,and postoperative prostate specific antigen (PSA) levels.Results LESS-RP was completed for all six cases without additional trocar placement or conversion to standard laparoscopic or open radical prostatectomy.The mean operative times were 252.5 (190.0-305.0) minutes,estimated blood loss was 300 (100-500 ml).There was no documentable intraoperative complication.The mean wound-drainage time was 5.2 (2.0-7.0) days,and the first postoperative day VAPS was 0.8 (0-3.0).Final pathological staging was pT2aN0M0 in four cases and pT2cN0M0 in two cases.Surgical margins were negative for all cases.The one-month post-operative PSA was less than 0.02 ng/ml in each case.All patients were continent without pad usage at 1 year postoperatively.Conclusion The technique of pure LESS-RP is feasible and early outcomes are acceptable。

Abstract：Background The palpation method is widely used in clinical practice to identify the puncture site of combined spinal-epidural (CSE) blocks,but it is usually difficult to accurately locate the puncture site in obese parturients.Accurate identification of the puncture site is crucial for successful CSE block.The objective of this study was to evaluate the impact of ultrasound imaging on the success rate of CSE puncture in obese parturients.Methods Sixty obese parturients with a body mass index ≥30 kg/m2 who were scheduled for caesarean section were randomized into two equal-sized groups for location of the puncture site:an ultrasound group and a palpation group.The success rate of puncture at the first puncture site,the number of puncture attempts,duration of CSE procedure,time taken to determine the puncture site,and the depth of the epidural space were compared between groups.The frequencies of complications such as puncture site hemorrhage,neurological damage,and inadvertent dural puncture were also studied.Results There were no differences in age,body weight,height,body mass index,or gestational age between the two groups.The success rate of puncture at the first puncture site was significantly higher in the ultrasound group than the palpation group (100.00％ vs.70.00％,P=0.004).The number of puncture attempts was significantly lower in the ultrasound group than the palpation group (x2=6.708,P=0.035).The time taken for determining the puncture site was (0.30±0.12) minutes in the palpation group and (2.60±0.61) minutes in the ultrasound group (P ＜0.001).The duration of CSE procedure was (7.67±1.52) minutes in the palpation group and (9.37±1.35) minutes in the ultrasound group (P＜0.001).The depth of the epidural space was similar in both groups (P=0.586).Puncture site hemorrhage was observed in 6 (20.00％) patients in the palpation group and 2 (6.67％) patients in the ultrasound group (P=0.255).Conclusions Ultrasound imaging improves the rate of successful puncture at the first puncture site and decreases the number of puncture attempts.It facilitates CSE puncture in obese parturients。

Abstract：Tumor necrosis factor (TNF)-like weak inducer of apoptosis (TWEAK) is a member of the TNF superfamily of structurally related cytokines and is known to induce proliferation,migration,differentiation,apoptotic cell death,inflammation,and angiogenesis.These physiological processes are induced by the binding of TWEAK to fibroblast growth factor-inducible 14 (Fn14),a highly inducible cell-surface receptor that is linked to several intracellular signaling pathways,including the nuclear factor-κB (NF-κB) pathway.This review discusses the role of the TWEAK-Fn14 axis in several rheumatic diseases and the potential therapeutic benefits of modulation of the TWEAK-Fn14 pathway。