Objective To investigate the clinical efficacy and experiences of laparoscopic hepatectomy (LH) for segment Ⅶ and Ⅷ liver tumors.Methods The retrospective cross-sectional study was conducted.The clinicopathological data of 94 patients who underwent LH for segment lⅦ or Ⅷ liver tumors in the Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine from June 2010 to August 2016 were collected.The operating space for operation was built under laparoscopy.According to liver cirrhosis grading,tumor size,adjacent relationship with major blood vessels and residual liver volume,non-anatomical and anatomical hepatectomies were selected by patients.During the operation,tumors were precisely pinpointed and plane of liver resection was determined,and then proper instruments of liver partition and techniques of hepatic inflow occlusion were selected.Observation indicators:(1) surgical and postoperative recovery situations;(2) postoperative pathological examination;(3) follow-up and survival situation.Follow-up using outpatient examination and telephone interview was performed to detect the patients' survival up to July 2017.Measurement data with normal distribution were represented as (x)±s.Measurement data with skewed distribution were described as M (interquartile range).Survival rate was caculated by the Kaplan-Meier method.Results (1) Surgical and postoperative recovery situations:all 94 patients received successful operations,without perioperative death,including 73undergoing non-anatomical hepatectomy and 21 undergoing anatomical hepatectomy.Fourteen patients had conversion to open surgery and 27 received hepatic inflow occlusion.The median operation time,median volume of intraoperative blood loss and cases with intraoperative blood transfusion were respectively 187.5 minutes (75.0minutes),200 mL (200 mL) and 15.Eighteen patients had postoperative complications,including 6 with pleural effusion,6 with abdominal effusion,1 with wound infection,1 with abdominal infection,1 with venous thrombosis,1 with bleeding,1 with coagulation disorders and 1 with hepatic insufficiency.Clavien-Dindo classification of complications:11,1,5 and 1 patients were detected in grade Ⅰ,lⅡ,Ⅲ and Ⅳ,respectively.All complications were improved by symptomatic treatment.The median duration of hospital stay was 7 days (6 days).(2) Postoperative pathological examination:results of tumor pathological examination showed that 45,5,9 and 35 patients were respectively confirmed as hepatocellular carcinoma,cholangiocarcinoma,metastatic hepatic carcinoma and benign liver tumor.(3) Follow-up and survival situation:59 patients with malignant tumors were followed up for 6.0-52.0 months,with a median time of 42.6 months.Postoperative 1-and 3-year overall survival rates of 59 patients with malignant tumors were 98.3％ and 84.7％,respectively.Conclusions LH for segment Ⅶ and Ⅷ liver tumors which is conducted in experienced medical center is safe and feasible,with definite effects.Building operating space for operation under laparoscopy,determining precise positioning of the tumor and plane of liver resection,and selecting proper instruments of liver partition and techniques of hepatic inflow occlusion are the key points of successful operation.

Objective:To investigate the effect of modified York-Mason technique on urethrorectal fistula after radical prostatectomy.Methods:A retrospective analysis of clinical data from 20 patients with urethrorectal fistula after radical prostatectomy admitted to Shanghai Sixth People's Hospital from May 2016 to October 2022 was conducted. Patients’ average age was (76.6±4.2) years. The etiology was rectal injury during radical prostatectomy. Patients present urine leakage from the anus during micturition. 2 cases also had bladder neck stenosis, and 1 case had urinary incontinence.3 cases had radiotherapy history because of prostate cancer. The average duration of urethrorectal fistula was (1.8±2.3)years. Preoperative imaging confirmed the presence of contrast agent flowing from the bladder neck into the rectum. Three suspicious patients also underwent CT three-dimensional reconstruction. Urethroscopy revealed a depression at the bladder neck in five cases. Anorectal examination in five cases showed the formation of gas bubbles in the lower anterior wall of the rectum, along with a concave anterior wall. The distance from the fistula to the anal margin was (6.0±2.1) cm, with fistula diameters ≥1 cm in twelve cases, <1 cm in eight cases. Twelve patients had previously undergone cystotomy, and seventeen patients had undergone colostomy. The modified York-Mason procedure was adopted for all 20 cases. The patients were under general anesthesia and placed in the prone jackknife position, with the buttocks spread and fixed to the sides to expose the anus. An 8 cm-long incision was made from two points near the sacrococcygeal joint to the anal edge, representing the modified York-Mason approach. After dividing the anal sphincter muscle, both sides were marked using 3-0 chromium thread for subsequent anal reconstruction. The urethrorectal fistula was exposed, and the urethral side of the fistula was sutured with 4-0 absorbable thread, while the anterior rectal wall side was sutured with 3-0 absorbable thread. In cases of bladder neck stenosis, urethral internal incision was performed, and a urethral catheter was retained for 3 weeks postoperatively. Perianal incision drainage tubes were removed after three days. Patients had colostomy repair could eat the day after surgery, while those who didn’t were fast for five days and received intravenous nutrition.Results:All 20 cases in this group were successfully completed without complications during surgery. Follow-up ranged from 10 to 48 months after surgery. Seventeen (17/20)cases had unobstructed urination, with a maximum urine flow rate >15 ml, and no urine leakage from the anus. Postoperative urethrography and cystourethroscopy showed there were no urethrorectal fistulas in 15 cases. None of the patients experienced fecal incontinence after the surgery, except for three patients with a history of radiotherapy who continued to experience anal leakage. One patient underwent a second modified York-Mason procedure and achieved complete recovery three months after the second surgery. Another patient had anal discharge, and the fistula healed after two weeks of urethral catheter retention. One patient refused further treatment due to advanced age and frailty but still had anal leakage. Another patient experienced regular urethral dilation for urination difficulties, while one patient continued to have urinary incontinence.Conclusions:The modified York-Mason technique could be an effective method for urethrorectal fistula after radical prostatectomy with high success rate and few side effects.

Objective:To investigate the effect of gracilis flap in repair of radiation-induced vesicovaginal fistula.Methods:The data of 18 patients with radiation-induced vesicovaginal fistula treated in the Sixth People’s Hospital Affiliated to Shanghai Jiaotong University School of Medicine from March 2021 to August 2022 were retrospectively reviewed. Their age was (57.3±10.4) years. All patients underwent radical surgery for cervical cancer, and received (24.6±2.8)(range from 20 to 30)times of radiotherapy after surger. The median time between the end of radiotherapy and the onset of vesicovaginal fistula was 14.0(7.8, 18.2)months. The median duration of fistula urine was 12.0(9.8, 18.0)months. All patients were required to use median 19.5(15.8, 27.5) pads per day before surgery. The life quality score(QOL)of 18 cases was median 5.0(5.0, 6.0) points. Three cases had performed laparoscopic vesicovaginal fistula repair, two cases had underwent transvaginal vesicovaginal fistula repair, one case had underwent transvaginal and laparoscopic vesicovaginal fistula repair successively, and the remaining 12 cases were new vesicovaginal fistulas. Two cases were combined with rectovaginal fistulas. All patients underwent the repair of vesicovaginal fistula with gracilis flap interposition in prone and folded knife position, by transvaginal route, the vesicovaginal fistula was mobilized and the two layers were closed, and the vascular pedicle gracilis flap of left inner leg was romoved under the skin tunnel to repair the vesicovaginal fistula. Meanwhile, two cases combined rectovaginal fistulas were repaired and closed the rectovaginal fistulas. The urinary catheters were removed at 3 weeks after the operation and urination was recorded.Results:All patients underwent smooth surgery in (96.6±13.2) minutes. The median follow-up was 13.0(9.8, 20.2)(range from 6 to 24)months. The median number of urine pads used per day in 18 patients was 2.0(1.0, 11.8), and significantly reduced ( P<0.01).QOL score was median 1.0(0, 4.2) point and significantly reduced ( P<0.01).Successful outcome was achieved in 12 patients with no leakage of urine in the vagina. Two cases developed urinary incontinence and required conservative treatment, but the curative effect was poor. Two cases still had vaginal urine leakage performed vesicovaginal fistula repair again. One case was successfully repaired without significant urine leakage.The other case still had significant urine leakage and the QOL score was 3 points. She refused further treatment for self-satisfied. Two cases still had vesicovaginal fistula and rectovaginal fistula after the surgery, and refused further surgery. Conclusions:Repair with gracilis flap interposition is a surgical method with few complications and reliable surgical effect for patients with radiation-induced vesicovaginal fistula.