Esophagectomy is an effective treatment for esophageal cancer,and there has been growing attention on the importance of postoperative pain management in patients undergoing the surgery.Epidural analgesia is the preferred analgesic approach for open esophagectomy.With the development of surgical technology,minimally invasive esophagectomy(MIE)has become the mainstream surgical approach.However,no conclusion has been reached concerning whether epidural analgesia is still the preferred analgesic approach for MIE.Herein,we analyzed the relevant literature published in recent years and found that epidural analgesia continued to be an important analgesic approach for MIE,offering the best analgesic effect.Epidural analgesia can reduce postoperative pulmonary complications,improve the quality of life,and reduce the stress response.Adverse effects can be minimized through accurate selection of epidural puncture segments,individualized medication,and multimodal analgesia strategies.In the future,precision-based multimodal analgesia can be achieved using emerging technologies such as big data analytics and artificial intelligence.

Objective:To investigate the efficacy and safety of mini-track,mini-nephroscopy and mini-ultrasonic probe percutaneous nephrolithotomy(3mPCNL)for the treatment of 1.5-2.5 cm kidney stones.Methods:The perioperative data and postoperative follow-up data of a total of 25 patients with about 1.5-2.5 cm kidney stones who underwent 3mPCNL under ultrasound guidance in Peking Univer-sity People's Hospital from November 2023 to January 2024 were retrospectively analyzed.During the matching period,the 25 patients with 1.5-2.5 cm kidney stones receiving standard percutaneous neph-rolithotomy(sPCNL)were matched one-to-one according to the criterion that the absolute difference of the maximum diameter of stones between the two groups was less than 1 mm.The operative time,renal function changes,postoperative stone-free rate,hemoglobin changes,and complication rate of the two treatments were compared,and then the effectiveness and safety of 3mPCNL were preliminarily analyzed.Results:There were no significant differences in mean age,preoperative median creatinine,preoperative mean hemoglobin,preoperative mean hematocrit,median stone maximum diameter,and median stone CT density between the 3mPCNL group and the sPCNL group.The median operation time in the 3mPCNL group was 60.0(45.0-110.0)min,with no statistical significance compared with the sPCNL group,and all the patients underwent single-channel operations.The mean hemoglobin after operation in the 3mPCNL group was(115.3±15.5)mmol/L,and there was no significant difference between the preoperative group and the sPCNL group,and the mean hemoglobin decreased significantly between the sPCNL group and the sPCNL group[(9.5±2.2)mmol/L vs.(10.1±1.9)mmol/L].The mean hematocrit after operation was(28.0±5.2)％,and the difference was statistically significant compared with that before operation(t=2.414,P=0.020).The mean hematocrit drop was not statistically signi-ficant compared with the sPCNL group(2.3％vs.2.7％).The median serum creatinine in the 3mPCNL group was 74.0(51.0-118.0)μmol/L after operation,and the difference was statistically significant compared with that before operation(Z=-2.980,P=0.005).The stone-free rate in the 3mPCNL group and the sPCNL group was 96.0％and 97.3％,respectively,and the mean hospital stay was(4.3±1.4)d and(5.5±2.0)d,respectively,with the statistical significance(t=0.192,P=0.025).After the operation,one patient in sPCNL group had massive hemorrhage after the nephrostomy tube was re-moved,which was improved after selective renal artery embolization.One patient in the 3mPCNL group developed mild perirenal hematoma,which was improved after conservative treatment,and no complica-tions were observed in the other patients.Conclusion:3mPCNL in the treatment of 1.5-2.5 cm kidney stones can achieve an effective rate comparable to sPCNL,and can achieve the ideal stone-free rate in a shorter operative time with a lower rate of surgery-related complications.

Objectives:To validate the Chinese version of the Ureteral Stent Symptoms Questionnaire(Chinese-USSQ) in patients with an indwelling ureteral stent.Methods:The original USSQ was translated into Chinese and linguistically validated following the cross-cultural adaptation of health-related quality of life measures.A total of 83 patients (cases) with indwelling ureteral stent and 90 healthy subjects (controls) were asked to complete the Chinese-USSQ as well as European Quality of Life Visual Analogue scale(EQ-VAS)(for both genders), the International Prostate Symptom Scale (IPSS) (for male), and Urogenital Distress Inventory-6 (for female). Patients were evaluated at weeks 1 and 4 after stent placement and at week 4 after removal. The psychometric properties of the questionnaire were analyzed.Results:The Chinese version of USSQ include 43 items, which addressed various domains of health(6 sections) covering urinary symptoms, pain, general health, work performance and sexual matters with additional problems. A total of 78 patients(45 males and 33 females) and 90 controls (41 males and 49 females)were included for analysis. Internal consistencies (Cronbach′s α coefficients: 0.60-0.78) and test-retest reliability (Spearman correlation coefficient: 0.69-0.91) were satisfactory for urinary symptom, body pain, general health, and work performance domains. Most USSQ domains showed moderate correlations with each other. The convergent validity determined by correlation between other instruments and corresponding USSQ domain was satisfactory. At week 4 it was moderate for the urinary symptoms index compared to the IPSS in men(Spearman correlation coefficient>0.60), for the urinalry symptoms index compared to the UDI-6 score in women(Spearman correlation coefficient 0.52).Sensitivity to change and discriminant validity were also good in most domains ( P<0.01). Only a small proportion of the study population had an active sexual life with the stent in situ, which limited its analysis. Only 1(1.3%) and 6(7.7%) patients had an active sex life at week 1 and 4 after stent placement; meanwhile, 34(43.6%) patents were sexually active at week 4 after stent removal. Conclusion:The Chinese version of the USSQ is a reliable and valid instrument that can be used for Chinese patients with a indwelling ureteral stent in the clinical and research settings.

Objective:To discuss the clinical manifestation, diagnosis and treatment of upper urinary tract calculi complicating with emphysematous pyelonephritis(EPN).Methods:The clinical data of 5 cases of upper urinary tract calculi complicating with EPN diagnosed in our department from July 2012 to December 2019 were retrospectively analyzed, and literatures were reviewed. 5 patients were identified by computed tomography scanning to upper urinary tract calculi complicating with EPN, 3 female and 2 male, aged 40-67 years, 2 staghorn calculi and 3 multiple stones. One patient suffered from diabetes mellitus. All cases presented with fever at the enrollment point, and the body temperature were 38.7℃, 38.8℃, 37.5℃, 38.6℃, 40.0℃, respectively. And the number of white blood cells and neutrophile granulocyte of these cases were higher than normal reference value, were 17.2×10 9/L, 0.90; 14.9×10 9/L, 0.89; 11.2×10 9/L, 0.85; 15.1×10 9/L, 0.87; 13.3×10 9/L, 0.88, respectively. The C-reactive protein were increased in all of the cases, especially in case 1(68 mg/l), case 2(253 mg/l), and case 5(67 mg/l). And 3 cases with renal insufficiency. Case 3 and case 4 were controlled the infection with medical management alone, and case 5 with percutaneous drainage plus medical management. The pyelonephritis of other 2 cases were uncontrolled, the body temperature of case 1 returned to normal after treated with percutaneous drainage of perirenal abscess plus nephrostomy plus medical management, but the imaging findings of kidney was not relief by CT scan after 4 weeks. Case 2 was persistent fever until treated with fluconazole according to the medicine sensitive experiment’s result of urine culture after undergoing nephrostomy plus indwelled a double J tube in ureter, but the CT findings of kidney grew worse 1 week later. Results:Of the 5 patients, 1 received first-stage nephrostomy and second-stage percutaneous nephrolithotomy, 2 received same session surgery, 2 received nephrectomy. There was no complications occurred except postoperative fever in 1 case. Postoperative pathology of the nephrectomy revealed glomerular sclerosis, glomerulus dilation, and inflammatory granulation tissue was formed. And 1-84 months follow-up showed no recurrence in all the cases.Conclusions:Upper urinary tract calculi complicating with EPN is an rare acute severe infection, CT is the best choice of early diagnosis, double J stenting or percutaneous drainage of abscess with broad-spectrum antibiotics could be the preferred treatment.

Objective To analyze the incidence of urinary stone formation in the contralateral kidney of unilateral nephrectomy patients.Methods 1048 patients,including 596 males and 452 females,underwent unilateral nephrectomy from June 2010 to June 2016.Their age ranged from 16-87 years old (mean 58.7 years old).532 patients combined with components of metabolic syndrome and 213 patients with metabolic syndrome.164 patients had a previous history of urolithiasis.The incidence of urinary stone formation in the contralateral kidney after nephrectomy was recorded and analyzed.The urolithiasis incidences in different gender,age,comorbidity and history of urolithiasis patients after uninephrectomy were compared.Results All patients were followed up within 0.5 to 6 years (mean 3.2 years).89 patients suffered from urinary stones in the contralateral kidney after uninephrectomy.The incidence of urinary stone formation in the contralateral kidney was 8.5％ (89/1048),which was higher than that in general population of China.1％-5％.The urolithiasis incidence was 9.1％ (54/596)in male patients and 7.7％ (35/452)in female patients after nephrectomy.The incidence of urinary stone formation was 8.6％ (3/35)in patients aged under 30 years old,12.5％ (34/272) in patients aged 30-49 years old,7.3％ (37/504) in patients aged 50-69 years old,6.3％ (15/237)in patients aged 70 and over.The incidence of urinary stone formation was 12.2％ (65/532) in patients with components of metabolic syndrome after nephrectomy and 19.7％ (42/213) in patients with metabolic syndrome,while the incidence was 4.7％ (24/516)in patients without components of metabolic syndrome.In patients with history of urolithiasis,the incidence was up to 30.5％ (50/164) after nephrectomy,while 4.4％ (39/884)in patients without history of urolithiasis.Conclusions The incidence of urinary stone formation in the contralateral kidney of uninephrectomy patients was higher,especially in patients with metabolic syndrome or urolithiasis history.Patients after unilateral nephrectomy are more vulnerable to urolithiasis.

Objective: To evaluate the clinical effect and safety of retroperitoneal laparoscopic surgery combined with mini-flank incision hybrid surgery for partial nephrectomy of complex renal tumors.Methods: Between April 2015 and December 2016, the clinical data from 16 patients with complex renal tumors who underwent the hybrid surgery, including 10 males and 6 females, were retrospectively reviewed.The average age was (50.2±10.7) years, 9 cases were located in the left side and 7 cases in the right side, the mean tumor size was (6.1±1.0) cm, and the mean R.E.N.A.L.nephrometry score was 9.3±1.3.All the patients received the hybrid surgery, the first step was to adequately mobilize the kidney and tumor, prepared the renal artery by retroperitoneal laparoscopy, and then the incision about 10-12 cm was done under the twelve rib to convert to open surgery.After the renal artery was clamped, the tumor was removed and the wound was closed under direct vision.The operative time, ischemia time, estimated blood loss, intraoperative and postoperative complications and short-term renal function were recorded.Results: All the 16 patients'' hybrid surgeries were successfully performed.The mean operative time was (164.9±23.6) min, mean ischemia time was (32.4±6.2) min, and mean estimated blood loss was (204.0±125.1) mL.The mean drainage tube removal time was (4.1±1.0) d, and the mean postoperatively hospital stay was (6.9±1.5) d.There were 2 patients with Clavien Ⅲ grade complications.One patient was injured with collecting system, and 1 patient received a second emergency surgery for acute postoperative bleeding.The mean 1 day postoperative serum creatinine level was (126.3±26.4) μmol/L, which was statistically significant (P<0.05) compared with the preoperative serum creatinine level(74.3±16.9)μmol/L.There were no significant differences (P>0.05) in comparing the 1 month postoperative serum creatinine level(92.6±18.2) μmol/L, 3 months postoperative serum creatinine level (80.8±18.4) μmol/L with the preoperative serum creatinine level.During 3 to 20 months follow-up periods, no local recurrence or distant metastasis occurred.Conclusion: This hybrid surgery combined retroperitoneal laparoscopic surgery with mini-flank incision for partial nephrectomy is safe and effective.It could decrease the operative difficulty and be worthy of further application for some selected complex renal tumor patients.

Objective:To compare various data of open pyeloplasty,laparoscopic pyeloplasty and en-dopyelotomy as a treatment of ureteropelvic junction obstruction(UPJO),and to investigate and discuss the feasibility and effect of the three methods.Methods:In the study,109 cases of UPJO treated by dif-ferent surgical approaches in Peking University People’s Hospital from January 2004 to December 2014 were retrospectively investigated.The patients were divided into three groups according to the treatment they received:open peyloplasty group (32 cases),laparoscopic peyloplasty group (31 cases)and en-dopyelotomy group (46 cases).We compared the data of the operative time,intraoperative blood loss, perioperative complications and post-operative hospital stay among the three groups.The mean follow-up time was(51.9 ±40.1 )months (6 -132 months).Results:None of the laparoscopic peyloplties was converted to open peyloplasty.All endpyelotomies were successfully completed.The operative time was as follows:laparoscopic peyloplasty group (195.97 ±55.22)min,open peyloplasty group (121.19 ± 33.95)min and endopyelotomy group (74.04 ±33.95 )min,and there were significant differences among the three groups respectively(P <0.001 ).There was no significant difference on the operative blood loss between open peyloplasty group and laparoscopic peyloplasty group (P =0.163).The opera-tive blood loss of endopyelotomy group was 5(0,310)mL,which was lower than the other two groups,and this result had significant differences with the other two groups respectively(P <0.001).There were sig-nificant differences on the post-operative hospital stay (days)among open peyloplasty group,laparoscopic peyloplasty group and endopeylotomy group (P <0.05,respectively).The success rate was comparable between open peyloplasty group and laparoscopic peyloplasty group(93.8% vs.90.3%,P =0.672), while the endopeylotomy group had a lower success rate compared with both open surgery group and laparo-scopic group(69.6% vs.93.8%,P =0.01;69.6% vs.90.3%,P =0.048,respectively).The complica-tion rates of open peyloplasty group,laparoscopic peyloplasty group and endopeylotomy group were compa-rable(15.6%,16.1% and 13.0%,respectively,P >0.05).Conclusion:The laparoscopic peyloplasty group had a longer operative time than open peyloplasty group,while its post-operative stay was shorter. There was no significant difference on the operative blood loss between open peyloplasty group and laparo-scopic peyloplasty group.Although the success rate of endopyelotomy was lower than those of the other two groups,it had advantages over the aspect of operative time,operative blood loss and post operative stay.

Objective:To evaluate the clinical effect of retroperitoneoscopic renal pedicle lymphatic disconnection via extra-adipose capsule in the management of chyluria and to discuss the management of its complications.Methods:From August 2013 to June 2008,five patients with chyluria were admitted. All the patients were female,aged from 26 to 73 years,and disease course from 1 to 10 years.All the five patients had complained of intermittently voiding milky urine with varying degrees of weight loss,and fa-tigue,of whom two presented with flank pain and one with anemia.Their urine chyle tests were con-firmed to be positive.Preoperative cystoscopy found that chyluria was from the left side in 3 cases,and from the right side in 2 cases.Their proteinuria ranged from +to ++++.All the cases had been treated with the modified procedure by which lymphatic ligation was performed to hilar vessels and proximalureter via extra-adiposecapsule without disconnection of perirenal fat tissues.The operation time,intraoperative blood loss,postoperative intestinal function recovery,catheter time,drainage tube removal time and com-plications during operation were collected.Results:All the five cases were performed successfully.The operation time ranged from 75 to 170 minutes,mean (126.0 ±39.6)minutes,with the intraoperative blood loss 20 to 60 mL,mean (38.0 ±16.4)mL,and the postoperative intestinal function recovery time 1 to 3 days,mean (1.9 ±0.4)days.The catheter time was 1 to 4 days,mean (2.1 ±0.3)days and the drainage tube removal time ranged from 3 to 15 days,mean (9.3 ±1.8)days.Postoperatively lym-phorrhagia was found in two cases.No renal vessels injury occurred during operation.Chyluria of all the patients disappeared on the operation day with negative chyluria test after surgery.Furthermore,urine test revealed that proteinuria was totally negative.No recurrence was detected in our patients in the 9 to 31 months’follow-up.Conclusion:This modified procedure does not have to disconnect perirenal fat tissues and nephropexy during operation.It was characterized with shorter operation time,definitive effect and fewer complications.

Objective:To compare the efficacy and safety of tubeless percutaneous nephrolithotomy ( tubeless-PCNL) and ureteroscopic lithotripsy ( URL) in treatment of impacted upper-ureteral calculi ≥1.5 cm in size.Methods:Patients with ureteral stones sized ≥1.5 cm and lodged above the fourth lum-bar vertebra who were treated between September 2009 and July 2013 in Peking University People ’ s Hos-pital were retrospectively analyzed .In the study , 182 patients underwent tubeless-PCNL or URL treat-ment respectively , and the operation success rates were compared .The duration of operation , intraopera-tive blood loss ( average hemoglobin decrease ) , complications , mean hospital stay and residual stone rates were also compared.Results: Fifty-four patients underwent tubeless-PCNL treatment,the average stone size was (1.9 ±0.4) cm,nephrostomy tubes were placed in two patients ,and the operation success rate was 96.3%(52/54).In the rest of the 52 patients,and the mean operation time was (30.1 ±14.8) minutes with an average postoperative hemoglobin decrease of (10.2 ±6.1) g/L, and the mean hospital stay was (3.0 ±1.4) days.Only one of the patients had residual fragments (2%).The main complica-tions included minor perirenal hematoma in 1 patient, fever in 2 patients, elevated blood WBC in 11 patients,and analgesics requirement in 3 patients.In the study, 128 patients were treated with URL,the average stone size was (1.7 ±0.3) cm.19 procedures failed,and 10 patients were converted to PCNL, extracorporeal shock wave lithotripsy was executed subsequently after double -J stent placement in 5 patients,and migration of calculi or stone fragments happened in 4 patients.The mean operative time was (51.3 ±25.5) minutes for the remaining 109 patients with a hemoglobin reduction of (5.2 ±7.2) g/L. The mean hospital stay was (2.9 ±1.3) days, and residual stones were found in 13 of the 109 patients (11.9%).The main complications included fever in 3 patients, elevated blood WBC in 42 patients, an-algesics requirement in 13 patients because of pain in the urethra or flank .The size of the stones between the two group didn ’ t show significant difference ,but the success rate of the tubeless-PCNL procedure was significantly higher .Except that hemoglobin decrease was slightly higher in the tubeless-PCNL group ,the mean operative time , the rate of residual stones and rate of complications of the tubeless-PCNL group were lower significantly.Conclusion:Treating stones above 4th lumbar vertebra larger than 1.5 cm were challenging .It is difficult to treat these stones with URL because of a high probability to fail , but on the contrary, tubeless-PCNL was more likely to be performed successfully .For surgeons experienced with the PCNL technology, treating stones≥1.5 cm with tubeless-PCNL procedure may turn out to be more effi-cient and with a higher operation success rate , and the risk of complications was lower without lengthe-ning the postoperative hospital stay .

ObjectiveTo report our experience and assess the safety and efficacy of ultrasound-guided percutaneous nephrolithotomy (PCNL) with ultrasonic and pneumatic lithotripters for complete renal staghorn stones.MethodsFrom Jan 2006 to Jan 2015, 128 patients (142 kidneys) with complete staghorn stones underwent PCNL, included 14 patients with bilateral renal complete stones,13 patients with solitary or founctional solitary kidney, 22 patients with renal insufficiency, 25 patients with renal empyema, 4 patients with spine malformation, ultrasound-guided PCNL were performed. Stones were fragmented and cleared using a combination of ultrasonic and pneumatic lithotripters.ResultsAll PCNL procedures were successful. Successful access to the collecting system was 100%. Mean operation time was 64.5±39. 1min (range 30–150). The primary stone-free rate of PCNL was 76.8%(109/142). Most of the renal stones(63.4%, 90/142)were managed satisfactorily by a single tract,a second tract was used in 25 renal stones(17.6%, 25/142). There were 36 auxiliary procedures (24 second PCNL and 3 third PCNL and 9 extracorporeal shock wave lithotripsy). One month after treatment, the overall stone-free rate was 85.2%(121/142). Six patients (4.2%) received blood transfusion,three patients(2.1%) received angiography and embolization . Three patients (2.1%) with infective shock were cured by intravenous antibiotics and antishock treatments. Three patients with temporary renal function receded were observed in solitary kidney for two tracts PCNL. No other severe complications occurred. The mean postoperative stay was 5.2 days (range 2–12). Conclusion: Ultrasound-guided Percutaneous Nephrolithotomy with ultrasonic and pneumatic lithotripters for management of renal complete staghorn stones is safe, effective, and worthy of wider use in clinical practice.