Objective To evaluate the technique of finger palpation in thoracoscopic localization in patients with pulmonary nodules,and to summarize its technical details,especially with exploit of chest computed tomography (CT) facilitating it.Methods 95 patients with total amount of 109 pulmonary nodes 20 mm or smaller in size shown with lung window of CT,were reviewed.They were located subpleurally,with a median depth of 8.2 mm and a median size of 10.0 mm.The value of their depth over their size (D/d value) could be used as the extent of localizing difficulty.Each node had its own radiographic fealures for being localized,which was built preoperatively.Under thoracoscopic vision,nodules were finger-palpated by index finger via the 4th or 5th intercostal space on anterior axillary line,followed by wedgectomy or lobectomy for instant histopathological diagnosis to further decide the final surgical type.The distance between the nodule and the origin of segmental bronchus (L value) were also calculated out,as it might be relevant to the way the nodule could be biopsied.Results All nodules were successfully localized and resected for biopsy goal,105 by wedgectomy,4 by lobectomy.After intraoperative diagnosis was made by the pathologist,VATS lobectomy and lymph node dissection were further performed in 55 patients.L value of 4 cases being biopsied by lobectomy ranged from 18.3 to 30.3 mm,averaging 26.1 mm.Conclusion Finger palpation is viable in any cases of pulmonary nodules.Detailed reference of CT digital information,and enough detachment of mediastinal pleura,can greatly facilitate thoracoscopic localization by finger palpation.Lobectomy or segementectomy is preferable when L value is less than 30 mm.

Objective To investigate the clinic efficacy of two section and three leaves approach on laparoscopic radical cystectomy (LRC) or robot assisted radical cystectomy (RARC).Methods A retrospective statistical analysis collected a total of 103 cases with bladder cancer undergoing LRC or RARC,from Jan 2013 to Dec 2015 in our center.Those patients were divided into two groups,including two section and three leaves approach group (46 cases) and conventional group (57 cases).The two section,which means that to cut lateral prostate gland and lateral vesical gland respectively,the three leaves include lateral lobe of lateral vesical gland (superior vesical arteries and veins),medial lobe of lateral vesical gland and lateral prostate gland.In two groups,whose age ranged from 35 to 84 years,the median age were (63.3 ± 9.8) years and (63.7 ± 9.1) years,respectively.The median BMI values were (23.2 ± 2.9) kg/m2 and (23.0 ± 2.2) kg/m2,respectively.The occurrence of history of abdominal surgery were 4 (8.7％) cases and 9(15.8％) cases,respectively.In two section and three leaves approach,the ASA scores of 1,2,3 were found in 5,35,6 cases,respectively.In conventional group,the ASA scores of 1,2,3 were found in 12,38,7 cases,respectively.The difference between two groups in age distribution,BMI value,ASA score,history of abdominal surgery,urinary diversion,surgical methods,pathological staging and grading had no statistical significance (P ＞ 0.05).Then,the operation time,the blood loss and the time to remove drainage tube,et al of the above two groups were compared.Patients with BMI≥24 kg/m2 in the two groups were 24 cases and 20 cases,respectively,following the strategy based on BMI ≥24 kg/m2 and BMI ＜ 24 kg/m2 to compare the difference of subgroups in the operation time and the bleeding amount,for the purpose of corroborating the applied effectiveness of two section and three leaves approach compared with the conventional measure on LRC or RARC for patients with BMI ≥ 24 kg/m2.Results All endoscopic operations were completed successfully.No conversion was recorded.In two groups,the median operation time were (255.1 ± 99.3) min and (284.2 ± 171.3) min,respectively,the difference was statistically significant (P =0.011).The blood loss was (233.1 ± 196.9)ml and (272.0 ±268.8) ml,respectively(P =0.009).The time to remove drainage tube were (10.6 ± 5.0) d and (9.9 ± 4.4) d,respectively (P =0.880).In addition,the difference in the intraoperative blood transfusion rate(10.9％ vs.21.1％),occurrence of lymph fistula (13.0％ vs.17.5％),gastric extubation time [(4.3 ± 1.9) d vs.(4.0 ± 1.9) d],time for flatus recovery [(3.9 ±1.2) d vs.(3.7 ± 1.7) d],the incidence of perioperative complications (26.1％ vs.36.8％) and postoperative hospital stay [(13.3 ± 5.5) d vs.(13.5 ± 4.8) d] were no statistical significance (P ＞0.05).The results of comparisons for patients with BMI ≥ 24 kg/m2 between subgroups included the operation time were (264.3 ± 68.1) min and (298.5 ± 80.2) min,respectively.The blood loss were (247.8 ± 199.4) ml and (295.3 ± 204.5) ml,respectively,both of them were statistical significance (P ＜0.05).The two section and three leaves approach was significantly better than those patients operated by conventional method.Conclusions Compared with conventional method undergoing LRC or RARC,two section and three leaves approach could shorten operative time and reduce the blood loss markedly,especially for patients with BMI≥24 kg/m2.

Objective To investigate the diagnostic value of narrow-band imaging for flat bladder lesions.Methods Forty-nine patients with flat bladder lesions diagnosed by white light cystoscopy + narrow-band imaging followed by transurethral resection were included.The diagnostic value of narrow-band imaging was evaluated based on postoperative pathological results.Results A total of 59 flat lesions were identified,in which 8 were normal urothelium,3 were chronic inflammation,1 was papillary urothelial neoplasm of low malignant potential,1 were mild dysplasia,1 was moderate dysplasia,1 were severe dysplasia,3 were carcinoma in situ,16 were low-grade papillary urothelial carcinoma,16 were high-grade papillary urothelial carcinoma,and 8 were invasive papillary urothelial carcinoma.For narrow-band imaging,the sensitivity was 86.7 ％ (39/45),specificity was 57.1％ (8/14),diagnostic accuracy was 79.7 ％ (47/ 59),false-positive rate was 42.9％ (6/14),positive predictive value was 86.7％ (39/45),negative predictive value was 57.1％ (8/14),area under ROC curve was 0.719.Among these lesions,the sensitivity and specificity for postoperative recurrent lesions were 100％ (3/3) and 40％ (2/5),respectively,and those for erythematous patch-like lesions were 90％ (9/10) and 100％ (4/4),respectively.Conclusion Narrow-band imaging can improve the detection rate for flat bladder tumor lesions,and reduce the risk for missed diagnosis under white light cystoscopy,especially for otherwise indistinguishable erythematous patch-like lesions.

Objective To perform an exploratory investigation on confocal laser endomicroscopy (CLE) in the diagnosis of malignant bladder tumour.Methods From June 10 to July 11,2017,6 male bladder cancer patients underwent white light cystoscopy (WLC) + CLE examination,aging 64-86 years (median 72 years).All patients received TURBT on suspected lesions.WLC and CLE imaging results were recorded and validated by pathologic specimens.Results Lesions confirmed by histopathology were 3 low grade non-invasive papillary urothelial carcinomas,1 high grade non-invasive papillary urothelial carcinoma,1 low grade invasive urothelial carcinoma,1 high grade invasive urothelial carcinoma,1 carcinoma in situ (CIS),1 high grade dysplasia,1 cystitis glandularis,1 chronic inflammation,and 1 scar tissue.For CLE images in the normal urothelium,three layers of cells with different presentation were observed,namely,the superficial umbrella cells,the intermediate cells smaller in size and uniformly shaped,and the capillary network in the lamina propria.For non-invasive urothelial carcinoma,tumour cells appeared as papillary lesions growing from fibrovascular cores,with low grade cells appearing monomorphic and more cohesively arranged,and high grade cells relatively pleomorphic,more disorganised and with tortuous blood vessels in the fibrovascular core.For invasive urothelial carcinoma,tumour cells invaded the lamina propria,with uniform appearances,poor cohesion and indistinct cellular borders,and high grade ones were more pleomorphic.CIS and inflammation both appeared as erythematous patch-like flat lesions under WLC and sometimes difficult to differentiate.Under CLE,the former appeared as dysplastic and disorganised cells with indistinct cellular borders,with intact lamina propria,and inflammatory cells were discovered as infiltrative clusters in the lamina propria that were uniformly shaped and loosely connected.Dysplasia appeared somewhat similar compared with CIS under WLC,but with lower cellular irregularity as confirmed with pathology.Cellular appearance and structure in scar tissue was similar to that in the normal urothelium,but superficial umbrella cells were more likely absent,with thinner cell layers,and inflammatory infiltration was sometimes discovered in the lamina propria.Conclusions CLE provides real-time cellular imaging of the urothelium,and shows promising potential for clinical diagnosis,especially in differentiating fiat urothelial lesions.Large prospective studies are required for further validation.