Trends of lymphadenectomy in upper tract urothelial carcinoma (UTUC) patients treated with radical nephroureterectomy

Introduction

To evaluate temporal trends in the delivery and extent of lymphadenectomy (LND) in radical nephroureterectomy (RNU) performed in upper tract urothelial carcinoma (UTUC) patients.

Methods

We evaluated a multi institutional collaborative database composed by 1512 consecutive patients diagnosed with UTUC treated with RNU between 1990 and 2016. Year of surgery were grouped in five periods: 1990–1996, 1997–2002, 2003–2007, 2008–2012 and 2013–2016. Data about LND were available for all patients and numbers of nodes removed and positive were reported by dedicate uropathologists. The Mann–Whitney and Chi square tests were used to compare the statistical significance of differences in medians and proportions, respectively.

Results

Five hundred forty-five patients (36.0%) received a concomitant LND while 967 (64.0%) did not; 41.9% of open RNU patients received a concomitant LND compared to 24.4% of laparoscopic RNU patients. The rate of concomitant LND increased with time in the overall, laparoscopic and open RNU patients (all p?<?0.03). Patients treated with open RNU also had an increasing likelihood to receive an adequate concomitant LND (p?<?0.001) while those undergoing a laparoscopic approach did not (p?=?0.1). Patients treated with concomitant LND had a median longer operative time of 20 min (p?=?0.01). There were no differences in perioperative outcomes and complications between patients who received a concomitant LND and those who did not (p?>?0.1).

Conclusion

Although an increased trend was observed, most patients treated with RNU did not receive LND. Surgeons using a laparoscopic RNU were less likely to perform a concomitant LND, and when done, they remove less nodes.

     

Change in prostate cancer presentation coinciding with USPSTF screening recommendations at a community-based urology practice

Objective

The benefits of prostate-specific antigen (PSA)–based prostate cancer screening are controversial. We sought to determine the change in prostate cancer presentation coinciding with the release of the United States Preventative Services Task Force recommendations against screening in a high-volume community-based urology practice.

Impact of Calcium and Two Doses of Vitamin D on Bone Metabolism in the Elderly: A Randomized Controlled Trial

The optimal dose of vitamin D to optimize bone metabolism in the elderly is unclear. We tested the hypothesis that vitamin D, at a dose higher than recommended by the Institute of Medicine (IOM), has a beneficial effect on bone remodeling and mass. In this double‐blind trial we randomized 257 overweight elderly subjects to receive 1000 mg of elemental calcium citrate/day, and the daily equivalent of 3750 IU/day or 600 IU/day of vitamin D3 for 1 year. The subjects’ mean age was 71 ± 4 years, body mass index 30 ± 4 kg/m², 55% were women, and 222 completed the 12‐month follow‐up. Mean serum 25 hydroxyvitamin D (25OHD) was 20 ng/mL, and rose to 26 ng/mL in the low‐dose arm, and 36 ng/mL in the high‐dose arm, at 1 year (p < 0.05). Plasma parathyroid hormone, osteocalcin, and C‐terminal telopeptide (Cross Laps) levels decreased significantly by 20% to 22% in both arms, but there were no differences between the two groups for any variable, at 6 or 12 months, with the exception of serum calcitriol, which was higher in the high‐dose group at 12 months. Bone mineral density (BMD) increased significantly at the total hip and lumbar spine, but not the femoral neck, in both study arms, whereas subtotal body BMD increased in the high‐dose group only, at 1 year. However, there were no significant differences in percent change BMD between the two study arms at any skeletal site. Subjects with serum 25OHD <20 ng/mL and PTH level >76 pg/mL showed a trend for higher BMD increments at all skeletal sites, in the high‐dose group, that reached significance at the hip. Adverse events were comparable in the two study arms. This controlled trial shows little additional benefit in vitamin D supplementation at a dose exceeding the IOM recommendation of 600 IU/day on BMD and bone markers, in overweight elderly individuals. © 2017 American Society for Bone and Mineral Research.     

三维可视化技术联合荷瘤门静脉流域分析在腹腔镜解剖性肝切除中的应用

背景与目的：解剖性肝切除术（AH）是以荷瘤门静脉流域为目标的肝切除,它符合精准肝切除的理念,已经逐步成为肝细胞癌（HCC）患者腹腔镜肝切除的主流。但是,在相当长的一段时间内,学术界对于HCC患者行AH在肿瘤学获益方面是否优于非解剖性肝切除术（NAH）仍有争议,而产生这种争议的原因可能是由于传统的手术依据—Couinaud肝脏分段法与患者现实肝脏脉管解剖学上的偏差,导致未能完全清除所有的荷瘤门静脉流域。三维（3D）可视化技术的普及可帮助外科医师在术前更加直观和充分地了解患者的肝内脉管走行及变异情况,做出最贴合实际的荷瘤门静脉流域分析,指导制定个体化的精准AH。在本文中,笔者结合临床经验就上述问题进行探讨并介绍腹腔镜下实施AH的步骤与体会。方法：回顾性分析中南大学湘雅医院肝脏外科2022年收治的2例HCC患者的临床资料,2例患者均为单个肿块,累及相邻2个肝段。术前通过专业软件进行肝脏及肿块的3D成像分析,将荷瘤门静脉及其流域设定为切除范围,同时兼顾手术标本能够满足最小安全切缘（1 cm）,否则需要纳入邻近1～2支门脉分支及其流域,适当扩大切除范围以满足安全切缘。术中采用3D腹腔镜,在低中心...     

The prevalence of hematologic and metabolic abnormalities during chronic kidney disease stages in different ethnic groups

We conducted an observational cross-sectional study to determine if the prevalence of hematologic and metabolic abnormalities in chronic kidney disease (CKD) varied in different ethnic groups. We used a CKD provincial database where a complete data set at the time of registration was available as well as an estimated glomerular filtration rate (eGFR), which showed using the abbreviated MDRD formula that the patients had CKD of stages 3-5. We included patients with self-reported race of Caucasian, Oriental Asian, or South Asian. Primary outcomes were the prevalence of at least one of the following: anemia, hypocalcemia, hyperphosphatemia, hyperparathyroidism, hypoalbuminemia, and three or more laboratory abnormalities. All definitions were consistent with K/DOQI guidelines. When compared with Caucasians, Oriental Asians and South Asians had a higher prevalence of many of the metabolic abnormalities during most stages of CKD and were more likely to have any abnormality at all levels of eGFR. The prevalence of three or more laboratory abnormalities was higher in Oriental Asians at all stages and in South Asians at some levels of eGFR. These results were unchanged or exaggerated when controlled for age, gender, diabetes, and a primary diagnosis of renal disease. Hence, it appears that South Asians and Oriental Asians have more laboratory abnormalities compared with Caucasians at most levels of eGFR.     

每搏量与脉搏压变异度对机器人辅助肝脏手术预测液体反应的价值

目的探讨每搏量变异度(stroke volume variation,SVV)、脉搏压变异度(pulse pressure variation,PPV)对机器人辅助肝脏手术预测液体的准确性及阈值变化的价值。方法选择拟在全身麻醉下行机器人辅助肝脏手术患者26例,全身麻醉后连续监测心率(HR)、平均动脉压(MAP)、每搏量(SV)、每搏量指数(SVI)、SVV、PPV等血流动力学指标,在反Trendelenburg体位下建立人工气腹后进行容量负荷试验,记录输液前后各血流动力学指标数值,然后以输液前后每搏量变异指数的差(ΔSVI)将患者分为两组,即有反应组(ΔSVI≥15%)和无反应组(ΔSVI<15%)组,绘制SVV和PPV判断扩容效应的受试者工作特征性(ROC)曲线,确定机器人辅助肝脏手术特殊的体位及气腹条件下SVV和PPV预测容量状况的准确性、诊断阈值及两者的相关性。结果 SVV和PPV判断扩容有效的ROC曲线下面积分别为0.830和0.875,SVV的诊断阈值为13.5%,PPV的诊断阈值为14.5%,两者的相关性为r=0.772(P<0.01)。结论 SVV和PPV均能准确预测机器人辅助肝脏手术中全身麻醉机械通气患者的容量状况,两者预测容量状况的准确性相似且呈正相关,但两者的诊断阈值较标准值均有所降低。     

内镜面罩在肥胖患者无痛胃镜检查中的应用

 目的 探讨内镜面罩对肥胖患者无痛胃镜检查应用的有效性和安全性。方法 选择体重指数(BMI)大于28 kg/m²的行无痛胃镜检查患者100例 , 随机分为两组, 每组50例, 一组采用内镜面罩给氧(T组), 另一组采用鼻导管吸氧(C组), 氧流量均设置为3～5 L/min。两组均静脉注射芬太尼(0.05 mg)、咪达唑仑(1 mg)、丙泊酚(1~2 mg/kg), 至患者睫毛反射消失开始检查, 检查中若有轻微体动及时追加丙泊酚用量。记录麻醉前(T₁)、麻醉后2 min(T₂)和操作结束时(T₃)患者的收缩压(SBP)、舒张压(DBP)、心率(HR)和脉搏氧饱和度(SpO₂), 以及胃镜检查时间和丙泊酚用药总量。结果 (1)两组T₂及T₃时SBP、DBP和HR与T₁相比均有所下降, 差异有统计学意义(P<0.05)。(2)在T₂时, C组受检者SpO₂下降明显, 检查中有6例 (12％)发生SpO₂＜90％, 与T₁比较, 差异有统计学意义(P<0.05);而T组受检者与T₁相比明显增加, 差异有统计学意义(P<0.05), T组SpO₂(99.26%±0.90%)明显高于 C组(92.68%±2.30%), 差异有统计学意义(P<0.05);T₃时, T组SpO₂ (99.58%±0.61%)也明显高于C组(96.24%±0.98%), 差异有统计学意义(P<0.05)。(3)两组患者胃镜操作时间及丙泊酚的用量相比, 差异无统计学意义。结论 肥胖患者无痛胃镜检查中使用内镜面罩给氧优于鼻导管给氧, 使无痛胃镜检查更为安全。