Abstract:Da Vinci robotic surgical system has many unique advantages, including 3D high-definition vision system, simulation wrist with high degree of freedom, automatically removing the physiologic hand tremor and allowing sitting position for the operators. It was introduced into Chinese mainland in 2006, and has been widely applied in many fields, especially in urology (accounting for 46% of all clinical fields). In this paper, we analyzed the latest 15 years' application data of robot-assisted laparoscopic technique in urology in China and discussed the application characteristics and existing problems.

Abstract:There are two surgical approaches commonly used in robot-assisted laparoscopy nephron-sparing surgery:retroperitoneal and transperitoneal approaches, both with their own advantages and disadvantages. After analyzing the advantages and disadvantages, we are the first to use a combined retroperitoneal and transperitoneal approach for laparoscopy nephron-sparing surgery in our center. This paper compares the characteristics of the three surgical approaches, and discusses their indications according to the renal tumor characteristics for robot-assisted laparoscopic nephron-sparing surgery.

Abstract:Objective To compare the clinical efficacy of robot-assisted partial nephrectomy (RAPN) and traditional laparoscopic partial nephrectomy (LPN) in the treatment of obese patients with early renal tumors. Methods The clinical data of 71 obese patients (body mass index [BMI] ≥ 28 kg/m²) with cT1N0M0 renal tumors, who receiving RAPN or LPN in our hospital between Jan. 2016 and Aug. 2018, were retrospectively collected. There were 22 males and 12 females in RAPN group (n=34), with a mean age of (51.2±13.4) years and a mean BMI of (30.36±2.21) kg/m². The mean tumor size, R.E.N.A.L. score and preoperative estimated glomerular filtration rate (eGFR) were (3.67±1.09) cm, 7.3±1.7 and (92.8±22.0) mL/(min·1.73 m²), respectively. The operation was performed by transperitoneal approach in seven cases and retroperitoneal approach in 27 cases. There were 26 males and 11 females in LPN group (n=37), with a mean age of (56.2±12.6) years and a mean BMI of (29.74±1.36) kg/m². The mean tumor size, R.E.N.A.L. score and preoperative eGFR were (3.37±0.93) cm, 6.9±1.6 and (90.4±22.4) mL/(min·1.73 m²), respectively. The operation was performed by transperitoneal approach in six cases and retroperitoneal approach in 31 cases. The operation time, estimated blood loss, intraoperative blood transfusion rate, warm ischemia time, intraoperative conversion rate, incidence of intra-and postoperative complications, positive surgical margin, postoperative hospital stay, and variation of eGFR from baseline were recorded and compared between the two groups. Results The partial nephrectomy operation was successfully completed in both groups with no intraoperative complications, and there was no intraoperative conversion to open surgery or radical nephrectomy. There were significant differences in warm ischemia time ([19.2±5.6] min vs [21.8±4.1] min) and postoperative hospital stay ([6.0±1.2] d vs [7.4±2.8] d) between the RAPN group and LPN group (both P<0.05). No significant differences were found in operation time ([153.0±33.3] min vs [140.1±32.3] min), estimated blood loss ([88.5±49.1] mL vs [106.2±72.0] mL), intraoperative blood transfusion rate (2.9% [1/34] vs 5.4% [2/37]), incidence of postoperative complications (0 vs 8.1% [3/37]) or variation of eGFR from baseline (2.1% [-4.8%, 9.3%] vs 5.8% [1.5%, 15.7%]) between the two groups (all P>0.05). Post-operation pathology results showed no positive surgical margin in the two groups. Conclusion Both RAPN and LPN are effective for the treatment of obese patients with early renal tumors. Compared with LPN, RAPN can reduce the warm ischemia time, shorten postoperative hospital stay, better protect renal function and accelerate postoperative recovery.

Abstract:Objective To investigate the clinical value of Mayo adhesive probability (MAP) score in the preoperative evaluation of robot-assisted laparoscopic partial nephrectomy (RAPN). Methods The clinical data of 229 patients with T1aN0M0 renal tumor who received RAPN by the same surgeon in Changzheng Hospital of Naval Medical University (Second Military Medical University) from Oct. 2016 to Oct. 2018 were retrospectively analyzed. There were 145 males and 84 females, with an average age of (53.14±11.84) years, including 122 cases of left renal tumor and 107 cases of right renal tumor. The preoperative estimated glomerular filtration rate (eGFR) was (100.24±24.35) mL/(min·1.73 m²). The patients were divided into two groups according to the MAP score:low-MAP group (MAP score ≤ 3, n=175) and high-MAP group (MAP score>3, n=54). The clinical data were compared between the two groups. Results The RAPN was successfully performed in all the 229 patients, with no intraoperative conversion to radical nephrectomy or open surgery. The operation time was (140.57±41.05) min, the intraoperative blood loss was (98.56±65.38) mL, the total transfusion rate was 7.9% (18/229), and the postoperative hospital stay was (6.41±2.39) days. Four patients had no renal artery blocking, 13 patients had selective branch artery blocking, and the rest patients had main renal artery blocking. The warm ischemia time of kidney was (17.73±7.91) min. Thirteen patients with Clavien-Dindo classification grade Ⅱ received perioperative blood transfusion therapy, four patients received digital subtraction angiography embolization for hemostasis due to postoperative hemorrhage, and one patient underwent emergency radical nephrectomy due to hemorrhage. All patients were discharged uneventfully after treatment. During a 1-year follow-up, no tumor recurrence or metastasis was found. The eGFR at the latest follow-up was (94.40±22.63) mL/(min·1.73 m²), significantly different from preoperation (P=0.001). Compared with the low-MAP group, the high-MAP group had significantly longer operation time ([152.51±39.53] min vs [136.91±41.15] min, P=0.015), more intraoperative blood loss ([123.11±93.15] mL vs [94.75±59.89] mL, P=0.029), higher Clavien-Dindo classification (45 cases [83.3%] in grade Ⅰ, eight [14.8%] in grade Ⅱ and one [1.9%] in grade Ⅲ vs 165 [94.3%] in grade Ⅰ, seven [4.0%] in grade Ⅱ and three [1.7%] in grade Ⅲ, P=0.019), and longer postoperative hospital stay ([7.04±3.32) d vs [6.21±2.01] d, P=0.027). Conclusion MAP score can be used to evaluate the risk of prolonged kidney and tumor dissociation time and increased bleeding in RAPN in advance, guiding clinicians to make better preoperative surgical plan.

Abstract:Objective To evaluate the efficacy and safety of robot-assisted laparoscopic partial nephrectomy (RAPN) for specific renal hilar tumors (hilar tumors close to the upper pole of kidney and straddling renal pedicle, HUS renal tumors). Methods The clinical data of patients who received RAPN from Feb. 2016 to Dec. 2018 in our hospital were retrospectively analyzed. A total of 13 cases with typical HUS renal tumors were selected, and 13 cases with non-HUS hilar tumors with similar R.E.N.A.L. score were selected as controls. The demographic data, perioperative results, complications, renal function changes and oncologic outcomes of the two groups were analyzed and compared. Results The maximal tumor size and R.E.N.A.L. score were comparable between the two groups. RAPN of three patients with HUS renal tumors were converted to open partial nephrectomy. The operation time ([132.92±22.33] min vs [110.85±20.97] min) and warm ischemia time ([28.08±6.29] min vs [22.15±5.87] min) were significantly longer in the HUS group compared with those in the non-HUS group (P<0.05). There were no significant differences in the estimated blood loss, transfusion rate, length of hospital stay, postoperative short-term renal function change, positive margin rate, complications, or trifecta rate between the two groups (all P>0.05). No recurrence, metastasis or death occurred in the two groups during the follow-up. Conclusion RAPN for HUS renal tumor requires longer operation time and warm ischemia time, and has higher conversion rate from RAPN to open surgery, so it is necessary to select surgery strategy according to tumor characteristics and operator's experience.

Abstract:Objective To compare the surgical efficacy of da Vinci robot-assisted laparoscopy and traditional laparoscopy in the treatment of complicated adrenal tumors, so as to explore the clinical prospects of da Vinci robot-assisted laparoscopic surgery for the diseases. Methods The clinical data of 47 patients with complicated adrenal tumors who were admitted to Ruijin Hospital of Shanghai Jiao Tong University School of Medicine from Mar. 2016 to Mar. 2019 were collected, with 25 cases in robot-assisted laparoscopy group and 22 cases in traditional laparoscopy group. The two groups were compared in terms of conversion to open surgery, operation time, intraoperative blood loss, postoperative drainage tube drawing time, hospital stay and hospitalization expenses. Results The surgery was successfully completed in robot-assisted laparoscopy group, while there were two cases of conversion to open surgery in traditional laparoscopy group. The differences in operation time between the robot-assisted laparoscopy group and traditional laparoscopy group were not statistically significant (159 [149, 168] min vs 165 [155, 194] min, P>0.05). Compared with traditional laparoscopy group, robot-assisted laparoscopy group had significantly less intraoperative blood loss (350 [250, 475] mL vs 550 [285, 615] mL, P<0.05], earlier drainage tube removal (3 [3, 4] d vs 4 [3, 4] d, P<0.05) and shorter hospital stay (6 [6, 7] d vs 7 [7, 8] d, P<0.05). However, hospitalization expenses in robot-assisted laparoscopy group were significantly higher than those in the traditional laparoscopy group (72 874.30 [72 398.60, 73 651.60] yuan vs 48 933.50 [43 978.60, 50 254.90] yuan, P<0.05). Conclusion Da Vinci robot-assisted laparoscopy has its own advantages in the treatment of complicated adrenal tumors, which is worthy of promotion in patients who can afford.

Abstract:Objective To evaluate the clinical efficacy of salvage robot-assisted laparoscopic pyeloplasty for recurrent ureteropelvic junction obstruction (UPJO) and summarize the surgical experience. Methods From Aug. 2015 to Jul. 2018, 27 patients with recurrent UPJO received salvage robot-assisted laparoscopic pyeloplasty in the Department of Urology, the First Medical Center of PLA General Hospital. There were 20 males and 7 females with a median age of 31 years (range, 12-63 years). Among them, 26 patients failed in the primary pyeloplasty and one patient had a history of secondary pyeloplasty. The perioperative data were recorded. Ultrasound and urine routine examination were done postoperatively during follow-up, and computed tomography urography or emission computed tomography was performed when necessary. Results All operations were successfully completed without converting to open surgery. The operation time was 105-360 min (mean [159.7±54.2] min), estimated blood loss was 10-100 mL (mean [36.3±20.2] mL), the time of catheter indwelling was 2-10 d (mean [4.2±2.4] d), the time of drainage tube indwelling was 3-7 d (mean [4.7±1.8] d), and the postoperative hospitalization time was 3-12 d (mean [4.4±2.9] d). Double-J ureteral catheters were removed 8 weeks postoperatively. The follow-up time was 12-36 months (mean [21.2±9.8] months). The hydronephrosis was relieved or disappeared in 26 cases and renal function was recovered to varying degrees, which reached the criterion of surgical cure. The thickness of renal parenchyma decreased in one case without any relief of obstruction, and ureteroscopy showed a narrow ring at the anastomotic site, which was relieved after the double-J ureteral catheter was placed, and the catheter was finally removed after 2 months. Conclusion Salvage robot-assisted laparoscopic pyeloplasty is a safe and feasible procedure for recurrent UPJO, with low incidence of complications and satisfactory results in ameliorating hydronephrosis and renal function. Robot-assisted laparoscopic pyeloplasty is recommended for recurrent UPJO when the corresponding facility and technique are available.

Abstract:Objective To summarize our clinical experience on robot-assisted laparoscopic radical cystectomy combined with orthotopic ileal neobladder in treating bladder cancer, and to evaluate its efficacy and safety. Methods The clinical data of bladder cancer patients, who underwent robot-assisted radical cystectomy combined with orthotopic ileal neobladder from Jan. 2019 to Dec. 2019, were retrospectively analyzed. All the 22 cases were males, aged 32-71 years, with a median age of 63 years. The perioperative data such as operation approach, operation time, extubation time and complications, postoperative pathological results, and the follow-up data such as tumor control and urinary continence were all recorded. Results The operation was successfully performed in all the 22 patients, with no conversion to open surgery. Four cases underwent single-site operation, and two cases underwent full-endoscopic orthotopic ileal neobladder. The operation time was 320-600 min (mean [420±36] min) and the intraoperative blood loss was 100-400 mL (mean [150±17] mL) in the patients, with no blood transfusion during the perioperative period. After surgery, the patients resumed ambulation 1-2 days (median 2 days), recovered bowel function 1-3 days (median 2 days), removed the negative pressure drainage 5-21 days (median 10 days), and removed the urinary catheter 10-25 days (median 14 days) postoperatively. No patients had intestinal complications such as intraoperative intestinal injury or postoperative intestinal obstruction, and there was no incision infection. Neobladder leakage occurred in two cases and recovered spontaneously by prolonged indwelling urinary catheterization. The postoperative pathological results were urothelial carcinoma in all the patients. No tumor recurrence or death occurred during a follow-up of 3-15 months. Twenty patients (90.9%) were satisfied with urinary continence 2 months postoperatively. One patient underwent surgery for internal hernia 4 months postoperatively, and two patients were given intermittent self-catheterization due to dysuria 6 months postoperatively. Conclusion Robot-assisted radical cystectomy combined with orthotopic ileal neobladder is clinically safe and feasible, with satisfactory short-term tumor control and urinary continence. The long-term efficacy needs to be further evaluated by case accumulation and long-term follow-up.

Abstract:Objective To study the safety and efficacy of robot-assisted laparoscopic radical prostatectomy (RARP) combined with expanded pelvic lymph node dissection (ePLND) in treating very high-risk locally advanced prostate cancer, and to explore the effects of neoadjuvant hormone therapy (NHT) and neoadjuvant chemotherapy combined with hormone therapy (NCHT) on postoperative pathological features. Methods The clinical data of 156 patients with very high-risk locally advanced prostate cancer who underwent RARP+ePLND between Oct. 2015 and Mar. 2019 were retrospectively analyzed. The initial prostate-specific antigen (PSA), initial tumor TNM stage, Gleason score, neoadjuvant regimen, operation time, decrease of postoperative hemoglobin, perioperative complications, length of hospital stay, and postoperative pathology were recorded. Results The mean age of the patients was (67.9±6.9) years, with a median initial PSA of 56.5 ng/mL (range 8.4-629.0 ng/mL). Patients with Gleason score ≥ 8 accounted for 63.5% (99/156), clinical stage ≥ cT3 accounted for 95.5% (149/156), and 35.3% (55/156) of the patients had pelvic regional lymph node metastasis. The average operation time was (186.7±35.5) min, the decrease of postoperative hemoglobin was (18.8±9.9) g/L, and the median hospital stay was 5 days (3-66 days). Two patients (1.3%) developed rectal injury and three patients (1.9%) developed vascular injury during extended lymphadenectomy. In 64.1% (100/156) of patients, PSA decreased to less than 0.2 ng/mL after RARP+ePLND, 6.4% (10/156) of patients had complete pathological remission (pT0), and 25.6% (40/156) of patients had positive margins. There were 51.3% (80/156) patients achieving pathological downstaging and 15.4% (24/156) patients having pathological upgrading. Thirty-five patients were treated with RARP+ePLND without neoadjuvant therapy (non-NT group), 54 patients underwent four to six cycles of NHT (NHT group), and 67 patients underwent four to six cycles of NCHT (NCHT group). The initial PSA and TNM stage in the NCHT group were significantly higher than those in NHT group and non-NT group (both P<0.01), but there was no significant difference in perioperative complications among the three groups. In the NHT group and NCHT group, the patients with complete PSA response were 72.2% (39/54) and 82.1% (55/67), respectively, which was significantly higher than 17.1% (6/35) in non-NT group (P<0.01). In addition, 57.4% (31/54) of patients in the NHT group and 68.7% (46/67) in NCHT group showed a decrease in pathological stage, compared with 8.6% (3/35) in non-NT group (P<0.01). Conclusion RARP+ePLND is safe and effective in the treatment of very high-risk locally advanced prostate cancer, and preoperative neoadjuvant therapy may gain higher surgical cure rate and more significant pathological downstaging effect without increasing perioperative complications.

Abstract:Objective To investigate the feasibility, safety and short-term recovery of urinary continence of the transvesical robot-assisted laparoscopic radical prostatectomy (RARP) for treatment of prostate cancer after holmium laser enucleation of prostate (HoLEP). Methods From Aug. 2016 to Apr. 2019, 12 patients confirmed with post-HoLEP prostatic cancer underwent transvesical RARP. The age of the patients ranged from 60 to 69 years. The preoperative prostate-specific antigen (PSA) was 1.5-8.7 ng/mL. The post-HoLEP Gleason score was ≤ 7 in all the 12 patients and preoperative TNM stage ranged from T1a-T1b. All patients were diagnosed as having prostate cancer by pathology after HoLEP, and none of them received endocrine therapy. The operation time, intraoperative blood loss and length of hospital stay were recorded. Results The operations of all the 12 cases were successfully completed without conversion to open surgery. The operation time was (116.2±15.1) min (115-130 min), the estimated blood loss was (125.1±20.3) mL (80-210 mL), and the postoperative hospital stay was (6.7±1.7) d (5-9 d). The catheter was removed 7 days after operation. No serious complications occurred. Eleven patients (91.7%) had immediate recovery of urinary continence, and one patient had no urine leakage after 2 weeks. Postoperative pathology showed that Gleason score was 6 in eight patients, 7 in two patients, 8 in one patient, and cancer tissue was not found in one patient. One patient with Gleason score of 8 was positive on the surgical margin at the apex of prostate. During 3 to 30 months of follow-up, all patients regained urinary continence 3 months postoperatively. Conclusion Early HoLEP surgery may increase the difficulty of radical prostatectomy. The transvesical RARP is a safe and technically feasible treatment for prostate cancer after HoLEP. The anatomical structure around the prostate associated with urinary continence is preserved as much as possible while achieving the goal of radical resection. The urethral catheter can be removed shortly after surgery and the urinary continence can be restored early.

Abstract:Objective To introduce our experience on three-step anatomical bladder neck preservation in robot-assisted laparoscopic radical prostatectomy (RARP). Methods A retrospective analysis was conducted on the clinical data of 30 patients with prostate tumors, who were admitted to our hospital and received three-step anatomical bladder neck preservation in RARP from Dec. 2017 to Dec. 2018. The procedures of three-step anatomical bladder neck preservation were as follows:(1) locate the bladder neck-prostate junction, separate the surface fatty tissue, and expose the anterior wall of urethra; (2) dissect from the loose tissue layer between the trigone of bladder and prostate to the deep layer, expose the anterior layer of seminal vesicle, then expose the lateral wall of urethra along this layer; (3) dissect and expose the posterior wall of urethra. The success rate of bladder neck preservation, the time of bladder neck preservation and the incidence of adverse events were observed and recorded. Results All the 30 patients received three-step anatomical bladder neck preservation in RARP. The success rate of anatomical bladder neck preservation was 93.3% (28/30). The bladder neck failed to be completely preserved in two patients because of the irregular protrusion of the middle lobe of prostate to the bladder. The time of bladder neck preservation was 8-10 min, with an average of (9.2±0.8) min. No adverse events occurred. Conclusion The three-step anatomical bladder neck preservation in RARP has a high success rate and is worth promoting.

Abstract:Objective To compare the surgical techniques and clinical outcomes between transvesical and posterior approaches for Retzius-sparing robot-assisted laparoscopic radical prostatectomy (RARP). Methods The clinical data of 35 patients with prostate tumors receiving Retzius-sparing RARP between Dec. 2016 and Dec. 2018 were retrospectively analyzed. Twenty-two cases underwent Retzius-sparing RARP via posterior approach (pRARP), and the preoperative data (total prostate-specific antigen [tPSA] [16.9±7.5] ng/mL, Gleason score 7 [5-8], prostate volume [42.3±11.2] mL and international index of erectile function-5 [IIEF-5] score 14 [9-20]) were documented, with nine cases at cT1c stage, four at cT2a, three at cT2b and six at cT2c. There were 13 cases in transvesical RARP (TvRARP) group, and the preoperative data (tPSA [18.6±8.7] ng/mL, Gleason score 6 [5-7], prostate volume [35.4±9.6] mL and IIEF-5 score 15 [10-21]) were also recorded, with eight cases at cT1c stage, two at cT2a, two at cT2b and one at cT2c. All patients had urinary continence preoperatively. Both pRARP and TvRARP were performed transperitoneally. The operation time, intraoperative blood loss, postoperative staging, postoperative Gleason score, recovery of urinary continence and postoperative IIEF-5 score were compared between the two groups. Results The operations were successfully completed in all the 35 cases without conversion to open surgery, blood transfusion or other major surgical complications. The operation time were (123.4±31.7) min and (135.3±25.6) min, and the estimated blood loss were (48.2±12.8) mL and (65.2±19.8) mL in pRARP and TvRARP groups, respectively, without significant differences (both P>0.05). Postoperative pathology confirmed six pT2a cases, six pT2b cases, eight pT2c cases and two pT3a cases in pRARP group, with Gleason score being 7 (5-8); and eight pT2a cases, three pT2b cases and two pT2c cases in TvRARP group, with Gleason score being 6 (5-7) (both P>0.05). Positive surgical margins were found in five cases (22.7%) in pRARP group and three cases (23.1%) in TvRARP group (P>0.05). Urethral catheter was removed at postoperative 7-day in both groups. Eighteen patients in pRARP group and 12 patients in TvRARP group achieved urinary continence (without pads) immediately after the removal of urinary catheter, while four patients in pRARP group and one patient in TvRARP group achieved urinary continence 2 weeks postoperatively (P>0.05). IIEF-5 score was 11 (4-13) in pRARP group and 12 (5-14) in TvRARP group 2 months postoperatively (P>0.05). There was no significant difference in IIEF-5 scores before and after operation in the two groups (both P>0.05). During a follow-up of 3-24 months, no biochemical recurrence was noted (tPSA<0.2 ng/mL). Conclusion The clinical outcomes of Retzius-sparing TvRARP for small localized prostate cancer are similar to those of Retzius-sparing pRARP, with satisfactory immediate postoperative urinary continence. Though the preservation of erectile function requires further follow-up, Retzius-sparing TvRARP is technically feasible and might be a valid alternative for localized low-risk prostate cancer.

Abstract:Objective To summarize the surgical experience on extraperitoneal suprapubic robot-assisted laparoscopic simple prostatectomy (RASP) in the treatment of benign prostatic hyperplasia (BPH), and to discuss the efficacy and safety of this procedure. Methods A retrospective analysis was conducted on the clinical data of 15 patients with BPH undergoing extraperitoneal suprapubic RASP from Apr. 2015 to Nov. 2018. The operation time, estimated blood loss, postoperative bladder irrigation time, postoperative drainage time, postoperative catheterization time, postoperative hospital stay and complications were recorded. The postoperative international prostate symptom score (IPSS), quality of life (QoL), post-voiding residual volume (PVR) and maximal flow rate (Q_max) were compared with those before operation. Results The operation was successfully completed in all the 15 cases. The operation time (console time) averaged (92.0±28.3) min, estimated blood loss averaged (105.0±42.5) mL, and no patient needed blood transfusion. The postoperative bladder irrigation averaged (2.2±0.5) days, postoperative drainage averaged (1.8±0.6) days, postoperative catheterization averaged (5.7±1.2) days, and postoperative hospital stay averaged (4.1±1.3) days. Clavien-Dindo gradeⅠcomplications occurred in three cases, and gradeⅡcomplications occurred in one case. After 3 months of follow-up, the values of IPSS, QoL, PVR and Q_max were significantly improved in the patients (all P<0.01). Conclusion Extraperitoneal suprapubic RASP is a safe and effective surgical procedure for the treatment of BPH.

Abstract:Objective To report the surgical procedure of removing renal foreign body by robot-assisted laparoscopic surgery in a child, so as to provide reference for future incidence. Methods and Results A 2-year-old girl was admitted to the hospital for a foreign body in right kidney, which had been found by abdomen X-ray for 1 month. She had been misdiagnosed as having a gastrointestinal tract foreign body, and it was not discharged after conservative observation for more than 3 weeks. Further examination was performed in our hospital, and abdominal computed tomography showed a foreign body in the right kidney. Robot-assisted laparoscopic surgery was conducted at the request of her parents. A foreign body was found in the inferior pole of the right kidney, and was intactly removed. The foreign body was a metal needle. The intra-operative blood loss was less and injury was small, with accurate location. No abnormal findings were noted during a follow-up of 44 months. Conclusion Robot-assisted laparoscopy can be used for pediatric renal foreign body removal, which provides a new method for removing visceral foreign bodies in children.

Abstract:Objective To establish a training system for robot-assisted laparoscopic partial nephrectomy (RAPN) based on virtual reality technology and segmented operation concept. Methods A urologist who has recently been qualified for da Vinci robotic surgery was selected to receive basic operation training and suture strengthening training using virtual reality technology. The procedures of the RAPN were divided into six steps. The trained doctor completed one step each time in the actual operation, and gained practical operation experience with minimal impact on patients. Finally, the trained urologist tried to carry out RAPN independently. Results The trained urologist successfully completed the virtual reality training, and participated in 18 cases of actual operation during the segmented operation. Compared with the operation carried out by superior doctor alone, the average operation time of the segmented operation was prolonged from (134±41) min to (161±51) min, but the difference was not statistically significant (P=0.087). There was no significant difference in perioperative indexes such as estimated blood loss, incidence of complications or postoperative hospital stay. After training, the trained urologist was able to carry out RAPN independently. Conclusion With the help of virtual reality training and segmented operation, the safety and efficacy of the RAPN can be guaranteed, and the trained urologist can complete the operation with high efficiency and quality.

Abstract:Objective To explore the effects of hepatocyte-specific overexpression of adenosine kinase (ADK) on glucose intolerance and hepatic steatosis induced by high fat diet in mice. Methods Twenty C57BL/6J male mice were randomly divided into two groups (n=10):the mice in one group were injected through tail vein with adeno-associated virus vector carrying thyroxine-binding globulin (TBG) promotor driven expression of ADK (AAV8-TBG-ADK group), while those in the other group were injected with control vector AAV8-TBG (AAV8-TBG group). After adeno-associated virus administration, the mice in the two groups were randomly divided into two subgroups (n=5) to receive normal or high fat diet for the following 8 weeks, and changes in mice body weight were recorded. Mice were sacrificed after modeling. The expressions of ADK in the liver were determined by Western blotting and quantitative real-time polymerase chain reaction (qRT-PCR). The glucose homeostasis was assessed by glucose tolerance test. The pathological changes and lipid deposition of liver tissues were detected by Hematoxylin-Eosin (H-E) staining and oil red O staining, respectively. The mRNA levels of gluconeogenesis related genes (glucose-6-phosphatase [G6P] and phosphoenolpyruvate carboxykinase [PEPCK]) and fatty acid synthesis related genes (sterol-regulatory element binding protein-1 [SREBP-1], acetyl-CoA carboxylase-1 [ACC-1], fatty acid synthase [FAS] and stearoyl-CoA desaturase-1 [SCD-1]) in liver tissues were analyzed by qRT-PCR. Results Compared with the normal diet subgroup, high fat diet induced weight gain, glucose intolerance and hepatic steatosis. There was no significant difference in the body weight between the AAV8-TBG and AAV8-TBG-ADK groups (P>0.05). Compared with the AAV8-TBG group, AAV-TBG-ADK mediated ADK overexpression significantly ameliorated high fat diet-induced glucose intolerance and hepatic steatosis (all P<0.05), and significantly reduced the mRNA levels of gluconeogenesis related genes and fatty acid synthesis related genes in liver tissues (all P<0.05). Conclusion Hepatocyte-specific overexpression of ADK can improve high fat diet-induced glucose intolerance and hepatic steatosis in mice.

Abstract:Objective To observe the effects of low-dose dexmedetomidine (DEX) on chronic pain-related depression-like behavior in rats and on the N-methyl-D-aspartate receptor 2B subunit (NR2B) in the prefontal cortex (PFC). Methods Twenty-two adult rats were randomly divided into Sham group (n=6), spared nerve injury (SNI) group (n=6), SNI+normal saline (NS) group (n=5) and SNI+DEX group (n=5). All rats of SNI+NS group and SNI+DEX group were intraperitoneally injected with an equal volume of NS or low-dose DEX (20 μg/kg) within 8-14 days after modeling. The von Frey test was used to evaluate the pain withdrawal threshold (PWT), and force swim test (FST) was used to evaluate rats' depression-like behavior. The expression of NR2B in PFC of rats was detected by Western blotting. Results Compared with the Sham group, the rats in SNI group had decreased PWT on day 1, 3, 7 and 14 after surgery, increased right leg immobility time and decreased NR2B protein expression in PFC on day 15 after surgery, and the differences were statistically significant (P<0.01, P<0.01, P<0.05). Compared with the SNI+NS group, the PWT of SNI+DEX group showed no significant changes (P>0.05) on day 1 to day 14 after surgery, the right leg immobility time in FST on day 15 after surgery was significantly decreased (P<0.01), and the expression of NR2B in PFC was significantly increased (P<0.05). Conclusion Intraperitoneal injection of a low-dose DEX may alleviate depression-like behavior associated with chronic neuropathic pain in rats, and the mechanism may be related to the increase of NR2B protein in PFC.

Abstract:Objective To investigate the expression of the immune checkpoint molecule programmed death ligand 1 (PD-L1) in non-small cell lung cancer (NSCLC) and its regulatory relationship with the microRNA-200 (miRNA-200) family, and to elucidate the clinical significance and regulatory mechanism of PD-L1 in NSCLC. Methods NSCLC cancer tissues and matched paracancerous tissues (138 cases) were selected for this study. The PD-L1 expression was detected by immunohistochemistry and the expression levels of miRNA-200 family (miRNA-200a, miRNA-200b, miRNA-200c, miRNA-429, and miRNA-141) were detected by quantitative real-time polymerase chain reaction (qRT-PCR). Lung cancer A549 cells were cultured and transfected with five miRNA mimics of miRNA-200 family. The effect of miRNA-200 family mimics on PD-L1 expression and proliferation activity of A549 cells were detected by Western blotting and cell counting kit-8 (CCK-8) assay, respectively. Luciferase reporter gene assay was used to elucidate the regulation of PD-L1 by miRNA-200 family. Results Total positive rate of PD-L1 in 138 NSCLC tissues was 58.7% (81/138), which was significantly higher than that in paracancerous tissues (3.6%, 5/138) (P<0.05). The expression level of PD-L1 was not related to the patients' gender, age, tumor size or histological types, but was closely related to lymph node metastasis, vascular invasion and clinical TNM stage (all P<0.05). The miRNA-200 family was expressed at a low level in NSCLC tissues than that in paracancerous tissues (all P<0.01), and patients with positive PD-L1 expression had significantly lower levels of miRNA-200 family expression (all P<0.01). Overexpression of miRNA-200 family in A549 cells significantly down-regulated PD-L1 and inhibited proliferation activity of cancer cells (all P<0.01). Luciferase reporter gene assay confirmed that the miRNA-200 family directly and negatively regulated the expression of PD-L1 (all P<0.01). Conclusion High expression of PD-L1 in NSCLC indicates poor prognosis. PD-L1 is the target gene of miRNA-200 family, and the low expression of miRNA-200 family may be an important reason for the high expression of PD-L1 in NSCLC.

Abstract:Objective To study the relationship between diabetic corneal neuropathy and diabetic retinopathy (DR) in patients with type 2 diabetic mellitus (T2DM). Methods A total of 58 T2DM patients (58 eyes) complicated with or without DR who were admitted to our hospital from Mar. 2017 to Aug. 2019 were selected for the study (case group), including 16 patients (16 eyes) with no diabetic retinopathy (NDR), 21 patients (21 eyes) with non-proliferative diabetic retinopathy (NPDR), and 21 patients (21 eyes) with proliferative diabetic retinopathy (PDR). Fifteen healthy people (15 eyes) without diabetes mellitus with similar ages were selected as controls (healthy group). Both the case group and the healthy group were examined by corneal confocal microscopy, and the images were analyzed quantitatively to compare corneal nerve fiber length (CNFL), corneal nerve fiber density (CNFD), and corneal nerve branch density (CNBD). Results CNFL, CNFD and CNBD of NDR, NPDR and PDR patients in case group were significantly lower than those in healthy group (all P<0.01). In case group, with the progression of DR, CNFL and CNFD gradually decreased (P<0.01, P<0.05). There was no significant difference in CNBD between NDR patients and NPDR patients (P>0.05). CNBD in PDR patients was significantly lower than that in NDR and NPDR patients (P<0.01, P<0.05). Conclusion Under corneal confocal microscope, the corneal nerve fiber damage in patients with T2DM appears earlier than DR, and it is related to the degree of DR, which can provide guidance for the diagnosis and treatment of DR.

Abstract:Neutrophils are the most abundant immune cells in human, and they can kill pathogens by chemotaxis, phagocytosis and direct sterilization. In recent years, neutrophil extracellular trap (NET), a new antibacterial way of neutrophils, has been found. NETs not only capture and kill pathogens by releasing the net-like structure formed by nucleic acid and granular proteins, but also participate in a number of human pathophysiological processes, such as tumor cell metastasis, inflammation, ischemia reperfusion injury, autoimmunity, etc. The central nervous system has once been regarded as a privileged part of the immune system. However, recent studies have found that in central nervous system injury such as trauma, inflammation and cerebrovascular diseases, there are large numbers of NETs formed in brain microvessels and parenchyma, which may aggravate the cerebrovascular and brain parenchyma damage. This article reviews the role of neutrophils and NETs in the development and progression of central nervous system injury.

Abstract:Inflammation and oxidative stress are two aspects of the pathology of many diseases, and they also promote each other, causing a vicious cycle of the disease. Hydrogen-rich water is the water rich in hydrogen. Studies have proved that hydrogen-rich water can selectively reduce hydroxyl radicals and ameliorate oxidative and inflammatory injuries to organs and tissues under different pathological conditions. In recent years, it has been found that hydrogen-rich water can improve the inflammatory conditions of rheumatoid arthritis, colitis, hepatitis, pancreatitis, etc. Its anti-inflammatory effects are related to the amelioration of oxidative stress and regulation of the signal transduction pathways such as p38-mitogen-activated protein kinase (p38-MAPK) and nuclear factor κB (NF-κB). In the present review, the anti-inflammatory activity of hydrogen-rich water and its molecular mechanisms are summarized and discussed.

Abstract:Objective To assess the short-term clinical efficacy and safety of radioactive ¹²⁵I sealed seed implantation in the treatment of local recurrence of thymoma. Methods A total of 42 patients with local recurrence of thymoma received ¹²⁵I sealed seeds brachytherapy in Huadong Hospital affiliated to Fudan University during Jan. 2015 and Dec. 2018. Surgical complications and postoperative radiation injuries were observed. Computed tomography (CT) scan was used to evaluate the change of tumor size, and then to calculate the tumor volume and the objective response rate before and after treatment. The local pain was evaluated by numerical rating scale (NRS) and the pain remission rate was calculated. Results All the 42 patients successfully received the operation. Low fever occurred in two patients, pneumothorax occurred in one patient, and local skin grade Ⅰ radiodermatitis occurred in two patients after implantation. No other adverse events occurred. The tumor volume was (37.2±8.4) cm³ before treatment, and it was (18.6±4.2), (15.3±4.0) and (14.9±3.7) cm³ at 2, 4 and 6 months after treatment, respectively. The objective response rate was 95.2% (40/42) at 6 months after treatment. Twenty-four patients had local pain before treatment, the median NRS score was 4 (1-9), and the NRS score decreased to 1 (0-6), 1 (0-5) and 1 (0-5) at 2, 4 and 6 months after treatment, respectively. The pain remission rate was 87.5% (21/24) at 6 months after treatment. Conclusion Radioactive ¹²⁵I sealed seed implantation is a safe and effective method in the treatment of local recurrence of thymoma, with a good short-term clinical efficacy and fewer complications.

Abstract:Objective To explore the relationship between high birth weight and childhood obesity, so as to provide scientific evidence for preventing and reducing childhood obesity. Methods A total of 70 284 Shanghai children aged 3-12 years were selected by multi-stage stratified cluster random sampling method. The age, gender, body weight, height, neonatal period data (including gestational week, birth weight and feeding pattern) were collected by questionnaire, and the relationship between high birth weight and childhood obesity was analyzed. Results There were significant differences in proportions of overweight, obesity and severe obesity between the high and normal birth weight groups (all P<0.05) in both boys and girls. After adjusting for age and gender by multivariate logistic regression model, we found that high birth weight was an independent risk factor for childhood overweight (OR=1.41, 95% CI 1.33-1.51, P<0.05), obesity (OR=1.45, 95% CI 1.31-1.62, P<0.05) and severe obesity (OR=1.51, 95% CI 1.35-1.68, P<0.05). After adjusting for age, gender and neonatal characteristics (including gestational week and feeding pattern), we found that high birth weight was still an independent risk factor for childhood overweight (OR=1.40, 95% CI 1.31-1.50, P<0.05), obesity (OR=1.44, 95% CI 1.28-1.61, P<0.05) and severe obesity (OR=1.42, 95% CI 1.25-1.60, P<0.05). Conclusion High birth weight is an important risk factor for overweight, obesity and severe obesity in children.