Objective:To present the learning curve of robotic assisted laparoscopic partial nephrectomy by a single surgeon.Methods:The clinical data of 100 patients with renal tumor who underwent robot assisted laparoscopic partial nephrectomy in Peking Union Medical College Hospital from February 2016 to April 2018 were retrospectively analyzed. There were 64 males and 36 females. The average age was 51.5(18-79) years. The average body mass index (BMI) was 24.9(19-31)kg/m 2. TNM stage was T 1N 0M 0, which indicated partial nephrectomy. The tumors were located on the left in 38 cases and on the right in 62 cases. The average maximum diameter of tumor was 3.9(1.0-6.7) cm, and the average R. E.N.A.L. score was 6.7(4-11). All operations were performed by a single surgeon. This group of operations were the first 100 robot cases for this surgeon. The mean machines docking time was 14(10-30) min, the mean operation time was 119.2(60-240) min, the mean warm ischemia time was 16.7(0-45) min, and the estimated mean blood loss was 105.2(30-500) ml. There was no conversion to open surgery or laparoscopic radical nephrectomy. No serious complications occurred (Dindo calvein grade ≥ grade Ⅲ). There were 1 case of lower extremity intramuscular venous thrombosis, 1 case of urinary fistula, 1 case of pulmonary infection and 1 case of peri-kidney hematoma after operation. All patients were cured after conservative treatment without further operation or intervention. Cumulative Sum (CUSUM) test was used to fit the learning curve of docking time and operation time, and to judge the three different learning stages of robot surgery according to the inflection of the curve (CUSUM stop rising, and CUSUM begin to decline). The characteristics of patients and perioperative data of different learning stages were compared. Result:According to the CUSUM, the learning curve of robot assisted laparoscopic partial nephrectomy was 19 cases. According to the inflection point of operation time learning curve, 100 cases could be divided into three stages, 1st-19th cases were learning stage, 20th-43rd cases were mastering stage and 44th-100th cases are proficient stage. There were no significant differences in age, gender, tumor side, intraoperative bleeding volume, postoperative pathological type, total cost of hospitalization and incidence of complications among the three stages ( P>0.05). The median BMI in the learning stage was significantly lower than that in the mastery stage and the proficiency stage (23 kg/m 2, 26 kg/m 2, 25 kg/m 2, P=0.02). The median docking time(20 min, 12 min, 12 min), median operation time (150 min, 120 min, 100 min) and median warm ischemia time (21 min, 18 min, 15 min)were gradually shortened in the learning stage, mastering stage and proficient stage ( P<0.001). The median length of postoperative hospital stay in mastering stage and proficient stage was shorter than that in learning stage (7 d, 6 d, 6 d, P=0.011). The median maximum diameter of tumor (3.7 cm, 3.9 cm, 4.0 cm)and median R. E.N.A.L. score (6, 7, 7)increased gradually in learning stage, mastering stage and proficient stage, but the difference was not statistically significant( P=0.75, P=0.16). Conclusions:The learning curve of robotic assisted laparoscopic partial nephrectomy for an experienced surgeon is about 19 cases. After the completion of the learning curve, the docking time, operation time, warm ischemia time and postoperative hospital stay of patients can be significantly shortened than the initial period, and more difficult renal tumor operations can be accomplished.

Objective:To investigate the safety and efficacy of domestic Kangduo robotic surgery system in adrenalectomy.Methods:This study summarized the clinical data of patients with adrenal adenoma who were operated by domestic kangduo robot from November 2020 to April 2021. This study was approved by the hospital ethics committee, and the clinical trials of medical devices were filed. Inclusion criteria: age 18-75 years old; all of them in accordance with the indication of adrenalectomy; tumor volume≤6 cm; agree to sign the informed consent, follow the doctor's advice and follow up regularly. Exclusion criteria: patients with ipsilateral upper abdominal surgery history; patients with severe uncontrolled disease or acute infection; patients with cardiovascular and cerebrovascular diseases, blood system diseases and immune system diseases that are not controlled and can not reach the operation standard; pregnant or lactating women. All patients underwent robot assisted adrenalectomy. The general information and perioperative data of the patients were summarized.Results:Five patients were included in this study, including 1 male and 4 female. The average age was 49 (34-61)years old. There were 2 cases on the left and 3 cases on the right. The average diameter of tumor was 2.2 (1.1-3.7) cm. All patients showed adenoma by CT examination. Two cases were diagnosed as primary aldosteronism, one as Cushing's syndrome, and two as nonfunctional adenoma. All the operations were successfully completed in 5 cases, including 4 cases via retroperitoneal approach and 1 case via peritoneal approach. The average docking time was 3.8 (3-6) min, the average operation time was 56.2 (21-92) min, and the average blood loss was 34 (20-50) ml. The postoperative pathology was adrenal cortical adenoma. The average postoperative hospital stay was 3.6 (3-5) days. No postoperative complications occurred in 5 cases. Two patients with primary aldosteronism had hypertension and hypokalemia before operation, and they needed oral antihypertensive drugs to control them. They did not need medication after operation, and their blood pressure and potassium were maintained at normal levels. All patients were followed up for average 1.5(0.5-5.0)months.Conclusions:Domestic robot assisted laparoscopic adrenalectomy has the advantages of few blood loss, short operation time, few complications. It’s a safe and effective operation, but the conclusion needs to be further verified by large sample and multi-center study.

[Objective]To retrieval a best cell factor which can induce bone marrow stromal cells (bMSCs) into chondrocyte in vitro and to explore an effective plan to repair rabbit's chondrocyte defect.[Method]Isolated bMSCs were cultured in vitro. rh Fibroblast Growth Factor 1(rhFGF-1)、rh Transforming Growth Factor-?1(rhTGF-?1)、rh Insulinlike Growth Factor-Ⅰ(rhTGF-Ⅰ) were utilizated. The proliferation of cells was detected by MTT assay, and the macroscopic histology , HE staining and immunohistochemical examinations were performed to seek the best cell factor. In vivo , to investigate the repair of the articular cartilage, bMSCs combined with fibrin glue and rhTGF-?1、rhIGF-I was compared with control group.[Result]The cells induced by rhTGF-?1 and rhIGF-I were similar to chondrocytes in morphology, and immunohistochemical examinations showed the cells possessed phenotype of chondrocytes. RhTGF-?1 and rhIGF-I could differentiate bone marrow stromal cells into cartilage cells in vivo, and repair the articular cartilage defect. The control group could not repair the articular cartilage defect efficiently.[Conclusion]rhTGF-?1 and rhIGF-I are best group which stimulate bMSCs to differenate into cartilage cells. BMSCs combined with fibrin glue and rhTGF-?1、rhIGF-I can repair the articular cartilage defect.

Objective To investigate the molecular mechanism of Klebsiella pneumoniae resistant to carbapenem. Methods The minimal inhibitory concentrations ( MICs) of the antimicrobial agents were determined by E-test. The 23 β-lactamase genes and 2 porin genes were amplified by polymerase chain reaction (PCR) , then the products were purified and their sequences were analyzed. Results The MICs of piperacillin, piperacillin/sulbactam, amoxicillin/clavulanic acid, cefoperazone/sulbactam, cefotaxime, cefepime and aztreonam to 5 strains of Klebsiella pneumoniae were all higher than 128 μg/mL, and those of imipenem or meropenem were higher than 32 μg/mL. All isolates carried blaTEM-1 and blaDHA-1 genes. Deletion of ompK35 and ompK36 were observed in Kp01 and Kp03, and the deletion of ompK35 was also observed in Kp02 and Kp05. Base insertion of ompK36 occurred in Kp02, Kp04 and Kp05. Compared with GenBank (GU945384) , ompK35 gene mutations of G→C at base 465 and T → C at base 466 in Kp04 lead to Gln to His substitution at position 155 and Tyr to its substitution at position 156, and it might be a new subtype. Conclusion The production of DHA-1 β-lactamase combined with the loss of OmpK36 or OmpK35 in porin genes may contribute to high-level carbapenem resistance in Klebsiella pneumoniae.

Objective To investigate the surgical treatment of severe ectopic adrenocorticotrophic hormone(ACTH) syndrome.Methods The clinical data of 12 cases of severe ecotopic ACTH syndrome from January 1996 to December 2016 were retrospectively analyzed.The cases include 7 males and 5 females with a mean age 38 years(range 11 to 64 years).12 cases demonstrated typical Cushing syndrome(CS),accompanied by hypertension, diabetes, hypokalemia and severe osteoporosis.9 cases were complicated with thoracolumbar compression fractures.8 cases presented with pulmonary infection and fever during operation.7 cases had cardiac dysfunction.Laboratory tests showed elevated serum cortisol(695.0 ～ 1 661.5 nmol/L,mean 1 055.7 nmol/L), high urinary free cortisol excretion (807.3 ～ 28 240.0 nmol/24 h, mean 5 270.5 nmol/24h)and high ACTH plasma levels(16.5 ～ 273.9 pmol/L, mean 80.4 pmol/L).Source of ectopic ATCH were not identified and CT showed bilateral enlargement of adrenal in 12 patients.Results We performed emergency bilateral or unilateral adrenalectomy in 12 cases.Among them, one-stage bilateral adrenalectomy were given to 6 cases, staged bilateral adrenalectomy was performed in 3 cases, and unilateral adrenalectomy were given to 3 cases.The patients were treated with hormone replacement therapy after bilateral adrenalectomy.The excised adrenal gland showed diffuse thickening and multiple nodular.Pathological diagnosis were adrenal cortical hyperplasia.They have been followed up for 1 to 8years(median 2.5 years), 9 cases survived, 2 cases died of diabetes and severe pulmonary infection, and 1 case was lost to follow-up.Conclusions Severe ectopic ACTH syndrome is difficult to treat.Emergency adrenalectomy is effective for the management of severe ectopic ACTH syndrome especially for those patients with severe Cushing syndrome but primary tumor can not be located.

Objective To explore the clinical and pathological characters of Xp1 1.2 translocation renal cell carcinoma.Method We screened patients of renal cell carcinoma of PUMCH between Jan.2011 and Dec.2015,6 patients with Xp11.2 translocation renal cell carcinoma were found.There were 2 males and 4 females,with average age of 39 (ranging from 16 to 73 years old).Diameter of tumor ranged from 1.9cm to 19.0cm,and 9.6cra in average.Among which,3 cases were detected by routine physical examination,1 by severe anemia (Hb 66g/L),1 by gross hematuria,and 1 by flank discomfort.Before treatment,2 cases had local metastasis (local lymph node,renal pelvis invasion),1 had distant metastasis (pulmonary metastasis).CT examination showed that the tumors had soft tissue density / low density,with significant enhancment or uneven enhancement in enhanced scanning,and were all considered malignancy.6 patients were all treated with surgeries,of which 5 patients received radical nephrectomy,1 patient received nephron sparing surgery.Result Pathologically,most clear cells arranged in a papillary,nest like structure,with psaamoma bodies in them.Immunohistochemical examination showed that all patients were positive for TFE3.AE1/AE3,RCC,Vimentin,CD10,EMA,P504 were positive in different degree.According to pathological result,all 6 patients were proved to be Xp1 1.2 translocation renal cell carcinoma.After surgery,2 patients received immunotherapy,2 received targeted drug therapy,and 1 received local radiotherapy.The follow-up duration ranged from 9 to 56 months (average 37 months).Among which,1 patient died from tumor recurrence and multiple metastasis 22 months after surgery,1 had pulmonary metastasis 12 months after surgery,and the tumor had no significant progress after receiving targeted drug therapy.All the other patients survive without tumor recurrence.Conclusions Xp1 1.2 translocation renal cell carcinoma predominantly occurs in children and adults younger than 40 years.Arterial phase enhancement is slightly lower for Xp1 1.2 translocation renal cell carcinoma in CT scan than that of renal clear cell carcinoma.Histological features and immunohistochemical staining of TFE3 positive expression are important means of diagnosis of this disease.If necessary,gene detection could be done to make better diagnose.Surgery is preferred treatment option.Metastatic leads to poor prognosis,and need to be supplemented by targeted drug therapy.

Objective To evaluate the safety and efficacy of QUILLTM self-retaining suture (QUILLTMSRS) in laparoscopie partial nephrectomy.Methods Sixty-three patients (39 males,24 females) with renal tumor accepted laparoscopic partial nephrectomy in Peking Union Medical Hospital from February 2012 to January 2013.The ages ranged from 38 to 75 years.The tumor sizes varied from 1.5 cm to 4.5 cm.According to the device of renorrhaphy,they were divided into 2 groups.Vicryl suture was used for renorrhaphy in 32 patients (Group 1),and QUILLTMSRS was used in 31 patients (Group 2).Renorrhaphy was performed in two layers for both groups,with a closure of deep vessels and the collecting system with 4-0 absorbable suture,followed by a running closure of the renal parenchyma and renal capsule.Demographical and perioperative parameters including age,body mass index,tumor size,R.E.N.A.L score,estimated blood loss,warm ischemic time,length of hospital stay were recorded and compared between the 2 groups.Results Renorrhaphy was successfully performed in all the 63 cases without conversion to open procedure or nephrectomy.The estimated blood loss and length of postoperative hospital stay were not significantly different between the 2 groups (P＞0.05).But warm ischemic time was significantly shorter in QUILLTM SRS group than that in Vicryl group (22.2 vs 26.7 min,P＜0.001).Conclusions QUILLTMSRS could be safe and effective for renorrhaphy in laparoscopic partial nephrectomy.It could make laparoscopic renorrhaphy easier and reduce warm ischemic time significantly.

Objective: To investigation the diagnosis and treatment of ectopic adrenocorticotrophic hormone (ACTH) syndrome.Methods: The clinical characters of 57 cases of ecotopic ACTH syndrome from Jan.1996 to Dec.2016 were collected and analyzed.The 57 cases included 32 males and 25 females.The age ranged from 11 to 68 years (average 32 years).ACTH levels significantly increased from 16.5 to 365.6 pmol/L, with average 77.6 pmol/L (normal range <10.1 pmol/L).The pituitary MRI did not found lesions.The CT showed that their bilateral adrenal glands diffused small nodular changes or nodular hyperplasia.The 57 cases were divided into 3 groups according to different treatment options.In the study, 25 ectopic ACTH syndrome cases (44%) were group A, without identified source of ectopic hormone, were treated with bilateral or unilateral adrenalectomy due to the severity of the disease and difficulty of operation.Group B was composed of 16 cases (28%) diagnosed as ectopic ACTH syndrome by finding ectopic ACTH tumors and surgical resection.Group C included 16 cases (28%) with nonsurgical therapy.Different treatment results and prognosis were analyzed.Results: In the study, 40 cases of the 57 had been followed up for 6 months to 10 years.In group A, of the 25 cases with bilateral or unilateral adrenalectomy, 4 died of diabetes and severe pulmonary infection, 18 survived, and 3 were lost to the follow-up, and the survival rate was 81% (18/22).In group B, of the 16 cases with radical tumor resection, 5 died of tumor recurrence 0.5-6.0 years after operation, 3 survived, and 8 were lost to the follow-up, and the survival rate was 37.5% (3/8).In group C, of the 16 non-operation patients, 4 with radiotherapy and chemotherapy died of metastases, diabetes or pulmonary infection, 6 with chemotherapy died of pulmonary infection within 1 year and the others were lost to the follow-up, and the survival rate was 0.Conclusion: Ectopic ACTH syndrome is difficult to treat.Adrenalectomy is effective for the management of ectopic ACTH syndrome, especially for those patients with severe Cushing''s syndrome, but the primary tumor can not be located.

Objective To observe the effects of the preconditioning of ulinastatin on GES-1 cell injury induced by oxygen and glucose deprivation (OGD). Methods GES-1 cells were cultured in vitro and divided into three groups: normal control group (group N), oxygen and glucose deprivation group (group O), and ulinastatin preconditioning group (group U). The OGD model of GES-1 cells were established by glucose-free medium and three-gas incubator for 6h. Ulinastatin was added to group U 12h before the deprivation of oxygen and glucose. The cell viability and apoptosis were determined by cck-8 and flow cytometry respectively. Western Blot was used to examine the protein expression of Caspase-3 and Cleaved Caspase-3. The TRPV1 mRNA expression was measured by quantitative real-time PCR. Results As compared with group N, the viability of GES-1 was decreased, the apoptotic rate and the expression of Caspase-3 and Cleaved Caspase-3 were increased, and the TRPV1 mRNA expression decreased greatly in group O (P < 0.05). As compared with group O, the aforementioned changes were significantly inhibited in group U. Conclusions Ulinastatin preconditioning could effectively inhibit GES-1 cell injury induced by OGD, which may be related to the inhibition of apoptosis and the upregulation of TRPV1 mRNA expression.

Objective To improve the experience of diagnosis and evaluate the clinical efficacy and safety of the surgical management for ureteral fibroepithelial polyp.Methods The clinical date of 29 patients with ureteral polyps admitted in Peking Union Medical College Hospital during 2001 to 2014 were analysed retrospectively.The patients' age was between 1 1 to 84 years and 19 were male.Twenty patients with frank pain and two patients with hematuria were enrolled.Seven patients were found hydronephrosis.Results Twenty-nine cases were treated surgically.Fifteen cases were treated by ureteroscopic laser ablation,10 cases local resection and reanastomosis,1 case of abnormalities duplex kidney and ureter underwent local resection and ureteroplasty,2 case Partial ureterectomy including the polyps and pyeloplasty,1 cases nephroureterectomy because of giant hydronephrosis and nonfunctional kidney.No recurrences were seen during a mean follow-up of 32 months (range 10-56 mos).No ureteral stricture occurs.Conclusions Ureteral fibroepithelial polyps represent a rare pathology.Local resection is the main treatment.Endoscopic management is recommended to minimize morbidity and complications in treatment of ureteral fibroepithelial polyps.Recurrences seem to be rare in these tumors.