Pneumothorax during pediatric laparoscopic surgery is a potentially fatal complication that may not be promptly recognized. It can occur due to congenital anatomical abnormalities, pre-existing pulmonary disease, or operative factors during laparoscopy. Clinical presentation may range from asymptomatic to acute respiratory distress, pleuritic chest pain, and even life-threatening circulatory collapse. Here, we report a case of sudden intraoperative pneumothorax accompanied by extensive subcutaneous emphysema of the neck and chest wall during laparoscopic high ligation of the hernial sac in a child. The child presented with a reducible left lower abdominal mass and mild pain 3 days prior but did not seek medical attention. Symptoms worsened 1 day prior to admission, with difficulty reducing the mass. On April 8, 2021, the patient was admitted to the Department of Anesthesiology, Zhuzhou Hospital Affiliated to Xiangya School of Medicine of Central South University, with a diagnosis of "left inguinal hernia." On the second day of hospitalization, laparoscopic high ligation of the left inguinal hernia sac was performed under general anesthesia. During the procedure, the patient developed a sudden increase in airway pressure, marked hemodynamic fluctuations, crepitus in the neck and right anterior chest regions, and significantly diminished breath sounds in the right lung. Emergent bedside chest X-ray confirmed a right-sided pneumothorax. Immediate intervention including thoracic needle decompression, closed thoracic drainage, the lung re-expansion was performed. The patient was discharged on the 7th postoperative day with full recovery. This case highlights the need for clinicians to remain vigilant for iatrogenic pneumothorax during pediatric laparoscopic surgery. Close intraoperative monitoring of vital signs is crucial for early detection, recognition, and timely management of pneumothorax to ensure patient safety during minimally invasive procedures.
Humans ; Laparoscopy/methods* ; Pneumothorax/etiology* ; Ligation/methods* ; Hernia, Inguinal/surgery* ; Male ; Intraoperative Complications/etiology* ; Child ; Herniorrhaphy/methods* ; Female ; Subcutaneous Emphysema/etiology*

With the rapid development of competitive sports, the incidence of anterior cruciate ligament (ACL) injury is on the rise. Such injuries may shorten athletes′ career and lead to other long-term adverse consequences. Although athletes generally recover well after ACL reconstruction, many still struggle to return to their pre-injury performance levels. Advances in the understanding of ACL anatomy and injury mechanisms, along with the evolution of surgical techniques and rehabilitation methods, have provided more individualized and tailored options for athletes following ACL injuries. However, there is currently no consensus in China regarding surgical and rehabilitation strategies for competitive athletes aiming to return to sports after ACL injuries. To this end, the Sports Medicine Committee of the Chinese Research Hospital Association and the Editorial Board of the Chinese Journal of Trauma jointly formulated the Expert consensus on surgical treatment and rehabilitation for competitive sports athletes returning to sports after anterior cruciate ligament injury ( version 2025), and presented 14 recommendations covering surgical indications, preoperative rehabilitation, surgical timing, surgical strategies and postoperative rehabilitation strategies, aiming to improve the surgical treatment and rehabilitation system for ACL injuries in competitive athletes and facilitate their return to high-level sports performance after injury.

Objective:To investigate the treatment strategies for vesicovaginal fistula（VVF）in women following cervical cancer radiotherapy.Methods:A retrospective analysis was performed on the clinical data of 33 female patients with post-radiotherapy VVF after cervical cancer treatment at Shanghai Sixth People’s Hospital between January 2020 and June 2024. The patients were categorized into three groups based on surgical approaches：Group A（11 patients）：Underwent prone-position VVF repair. Mean age：（50.0±9.6）years；mean radiotherapy sessions：（22.6±2.2）. All had simple VVF without concurrent intestinal or surrounding soft-tissue fistulas. Among them，1 patient previously received laparoscopic VVF repair，1 transvaginal VVF repair，and 2 gracilis muscle flap packing for VVF repair. One month prior to surgery，the average daily usage of urine pads was 16.7（12.8，25.7）pieces，and the quality of life（QOL）score stood at 4.0（4.0，5.0）points. Preoperative cystoscopy revealed that 8 cases had fistulas located in the trigonal region of the bladder，while 3 cases had fistulas on the posterior bladder wall. The diameter of the fistula openings，measured under a microscope，was 1.2（0.8，1.6）cm. Based on the Goh classification criteria for vesicovaginal fistulas，this group included 3 cases of type 1，4 cases of type 2，2 cases of type 3，and 2 cases of type 4；7 cases of type A and 4 cases of type B；as well as 3 cases of typeⅠ，7 cases of type Ⅱ，and 1 case of type Ⅲ.Group B（20 patients）：Underwent gracilis muscle flap packing for VVF repair. Mean age：（58.6±8.8）years；mean radiotherapy sessions：（29.8±3.9）. Three patients had concurrent rectovaginal fistulas and received colostomy for fecal diversion. History of previous interventions：3 had laparoscopic VVF repair，4 transvaginal VVF repair，and 1 both transvaginal and laparoscopic VVF repair. One month prior to surgery，the average daily usage of urine pads was 19.7（15.8，27.7）pieces，and the QOL score stood at 5.0（5.0，6.0）points. Preoperative cystoscopy revealed that 13 cases had fistulas located in the trigonal region of the bladder，while 7 cases had fistulas on the posterior bladder wall. The diameter of the fistula openings，measured under a microscope，was 1.8（1.0，3.2）cm. Based on the Goh classification criteria for vesicovaginal fistulas，this group included 4 cases of type 1，9 cases of type 2，3 cases of type 3，and 4 cases of type 4；6 cases of type A，11 cases of type B and 3 cases of type C；as well as 1 cases of type Ⅱ，and 19 case of type Ⅲ. Group C（2 patients）：Underwent ureterocutaneous diversion. Ages：67 and 73 years；radiotherapy sessions：51 and 60，respectively. Both had concurrent rectovaginal fistulas and bladder soft-tissue fistulas. The patient presented with recurrent thigh abscesses accompanied by fever. One month prior to surgery，the daily usage of urine pads was 29 and 23 pieces，respectively，and the QOL score was 6 points. Cystoscopic examination revealed that the vesicovaginal fistulas were located in the trigone of the bladder，with diameters of 3 cm and 4 cm，respectively. Additionally，partial defects were noted in the ventral wall of the urethra，while no bladder soft tissue fistulas were detected. According to the Goh classification for vesicovaginal fistulas，both cases were categorized as type 4，type C，and type Ⅲ. For Groups A and B，urinary catheters were indwelled for 3 weeks postoperatively，then removed to assess spontaneous urination and incontinence. QOL was evaluated，with a minimum 6-month follow-up. For confirmed postoperative VVF recurrence，re-repair was performed 3?6 months later based on patient preference. For Group C，double-J stents were placed in the ureters，and stoma bags were applied 3 days postoperatively. Stents were replaced every 1?2 months，with QOL assessment. Successful fistula repair in Groups A and B was defined as the absence of vaginal leakage confirmed by cystoscopy after six months of the procedure with no vaginal leakage. For Group C，surgical success was determined by the resolution of perineal urinary leakage and improvement in QOL.Results:All 33 patients completed surgery successfully. Group A：Follow-up duration：16.3（9.6，24.6）months. Surgical repair succeeded in 7 patients，with unobstructed spontaneous urination and no vaginal incontinence. Four patients had VVF recurrence：2 refused further treatment，and 2 underwent repeat gracilis muscle flap packing. One was successfully repaired，while one recurrence case refused further treatment. Group B：Follow-up duration：17.0（9.5，24.8）months（8?32 months）. Thirteen patients restored spontaneous urination without recurrence. Seven had recurrence：5 refused further surgery，and 2 underwent re-repair. One repair succeeded without incontinence，while one recurrence case refused treatment. Group C：Follow-up durations were 6 and 22 months. Perineum remained dry without incontinence（no urine pads needed），and no recurrence of thigh soft-tissue redness/infection occurred. QOL scores were 2 and 3，respectively.Conclusions:Post-radiotherapy VVF in women after cervical cancer presents complex and variable conditions. The primary goal of treatment should be to improve patients’ quality of life. Treatment approaches should be selected based on the complexity of urinary fistulas and local tissue conditions. In general，patients who are younger，have received lower doses of radiation therapy，present with smaller fistula diameters，have well-vascularized and elastic perifistular tissues，and have no concurrent tissue fistulas are candidates for prone-position VVF repair. Patients who do not meet the criteria for transvaginal repair，have a history of at least two previous repair attempts，or have concurrent vaginorectal fistulas require gracilis muscle flap packing for VVF repair. Patients with three or more types of concurrent tissue fistulas，extensive pale and inelastic perifistular tissues，and who are not amenable to repair surgery undergo ureterocutaneous diversion.

OBJECTIVE To establish an in vitro simulated one compartment extravascular adminis-tration model with lanthanum nitrate as the test substance,and explore the differences between this model and the classic in vitro administration model in lanthanum nitrate induced HepG2 cell death.METHODS An in vitro administration device was designed based on compartment model theories which consisted of four functional chambers:the liquid storage chamber,mixing chamber,toxicant exposure chamber,and waste liquid receiving chamber.The four chambers were connected by peristaltic pump hoses.The peristaltic pumps were employed to ensure unidirectional and constant speed trans-mission of liquid between these chambers.According to the preset toxicokinetic parameters such as T1/2a and T1/2,an in vitro simulated one compartment extravascular administration model of lanthanum nitrate was constructed using the device.The content of lanthanum nitrate in the toxicant exposure chamber at different time points was measured using inductively coupled plasma mass spectrometry.The concentration-time curves of lanthanum nitrate were analyzed using PKsolver and GraphPad Prism 8.0 software.The constructed in vitro simulated one compartment extravascular administration model was evaluated by comparing the measured and theoretical values of toxicokinetic parameters.HepG2 cells were treated with lanthanum nitrate in the in vitro simulated one compartment extravascular administration model and classic in vitro administration model,respectively,and cell death was measured using the Hoechst 33342/propidium iodide staining method.RESULTS Within the Cmax range of 3.91-1 000.00 μmol·L-1,the measured concentration-time curves of lanthanum nitrate in the toxicant expo-sure chamber almost conformed with the corresponding calculated theoretical curves(the correlation coefficients were all>0.998 0).The measured values of toxicokinetic parameters,including Ke,T1/2,Ka,T1/2a,Tmax,Cmax,CL and AUC0-∞,were close to the corresponding theoretical values.The fitting coeffi-cients(R2)of the concentration-time curves for each experimental group were all>0.990 0,which was consistent with one compartment model for extravascular administration.In the simulated one compart-ment extravascular administration model,no significant death of HepG2 cells was observed in any lanthanum nitrate dose group.In the classic in vitro administration model,the cell death rate of the 0.500 mmol·L-1 lanthanum nitrate group was higher than that of the solvent control group,but no significant cell death was observed in the 0.119 mmol·L-1 group or 0.243 mmol·L-1 group.When Cmax or Cadministration was 0.500 mmol·L-1,classic in vitro administration induced a higher cell death rate than simulated one compart-ment extravascular administration.However,there was no statistically significant difference in lanthanum nitrate induced HepG2 cell death between the two administration models when the AUC was equal.CONCLUSION The device designed in this study can be used to in vitro simulate one compartment extravascular administration,making in vitro toxicity testing more similar to in vivo scenarios,and providing data for optimizing administration methods of in vitro toxicity testing.There are differences in lanthanum nitrate induced HepG2 cell death between simulated one compartment extravascular administration and classic in vitro administration,indicating that different in vitro exposure modes can affect toxicity.

Objective:To explore the application value of transpubic access on female urogenital tract injury.Methods:A retrospective analysis was conducted on 15 female patients with urogenital tract injury caused by trauma admitted to our department from May 2020 to October 2024，all of whom were complicated urethral stricture or atresia，accompanied by urethrovaginal fistula or vaginorectal fistula. All patients underwent suprapubic vesicostomy before surgery，and 1 case underwent sigmoidostomy simultaneously. The mean age of the patients was（29.6 ± 3.2）years old，and the course of disease was 6-24 months. Preoperative urethrography and urethroscope showed the location of urethral stenosis，with proximal urethra stricture in 7 cases and distal urethra stricture in 8 cases. The average length of strictures was（2.8±0.2）cm. The urethral ultrasonography，magnetic resonance and CTU examination showed 8 patients were complicated with urethrovaginal fistula，and 1 patient was complicated with vaginorectal fistula. All patients underwent transpubic access and resection of symphysis pubis. According to the specific conditions of urethral stricture，7 of them underwent end-to-end urethral anastomosis，5 cases underwent bladder wall flap urethroplasty，3 cases underwent vulva flap urethroplasty，8 cases underwent urethral vaginal fistula repair，1 case underwent vagino-rectal fistula repair，and 7 cases underwent vaginoplasty during the operation.Results:All the 15 patients underwent successful operation without complication. After the catheter being removed 4 weeks after surgery，2 patients had urgent urinary incontinence and 3 patients had stress urinary incontinence. The bladder neck was reconstructed 3 months after surgery，the symptoms of urinary incontinence improved in 1 case，urinary incontinence remained in 2 cases，and pharmaceutical or physical therapy were continued. Two patients could not urinate normally after the catheter was removed and still carried the vesicostomy tube，waiting for further treatment. The other 8 patients had unobtrusive voiding after extubating，and were followed up for an average of（22.5±3.2）months. There was no recurrence of urinary fistula，and the average maximum urinary flow rate was（22.8±3.2）ml/s.Conclusions:The transpubic approach is a safe and effective way to treat female genital tract injury by different surgical methods according to specific conditions，especially for patients with severe trauma，poor local tissue conditions，complicated urethrovaginal fistula or vagino-rectal fistula.

Objective:To explore the application value of transpubic access on female urogenital tract injury.Methods:A retrospective analysis was conducted on 15 female patients with urogenital tract injury caused by trauma admitted to our department from May 2020 to October 2024，all of whom were complicated urethral stricture or atresia，accompanied by urethrovaginal fistula or vaginorectal fistula. All patients underwent suprapubic vesicostomy before surgery，and 1 case underwent sigmoidostomy simultaneously. The mean age of the patients was（29.6 ± 3.2）years old，and the course of disease was 6-24 months. Preoperative urethrography and urethroscope showed the location of urethral stenosis，with proximal urethra stricture in 7 cases and distal urethra stricture in 8 cases. The average length of strictures was（2.8±0.2）cm. The urethral ultrasonography，magnetic resonance and CTU examination showed 8 patients were complicated with urethrovaginal fistula，and 1 patient was complicated with vaginorectal fistula. All patients underwent transpubic access and resection of symphysis pubis. According to the specific conditions of urethral stricture，7 of them underwent end-to-end urethral anastomosis，5 cases underwent bladder wall flap urethroplasty，3 cases underwent vulva flap urethroplasty，8 cases underwent urethral vaginal fistula repair，1 case underwent vagino-rectal fistula repair，and 7 cases underwent vaginoplasty during the operation.Results:All the 15 patients underwent successful operation without complication. After the catheter being removed 4 weeks after surgery，2 patients had urgent urinary incontinence and 3 patients had stress urinary incontinence. The bladder neck was reconstructed 3 months after surgery，the symptoms of urinary incontinence improved in 1 case，urinary incontinence remained in 2 cases，and pharmaceutical or physical therapy were continued. Two patients could not urinate normally after the catheter was removed and still carried the vesicostomy tube，waiting for further treatment. The other 8 patients had unobtrusive voiding after extubating，and were followed up for an average of（22.5±3.2）months. There was no recurrence of urinary fistula，and the average maximum urinary flow rate was（22.8±3.2）ml/s.Conclusions:The transpubic approach is a safe and effective way to treat female genital tract injury by different surgical methods according to specific conditions，especially for patients with severe trauma，poor local tissue conditions，complicated urethrovaginal fistula or vagino-rectal fistula.

OBJECTIVE To establish an in vitro simulated one compartment extravascular adminis-tration model with lanthanum nitrate as the test substance,and explore the differences between this model and the classic in vitro administration model in lanthanum nitrate induced HepG2 cell death.METHODS An in vitro administration device was designed based on compartment model theories which consisted of four functional chambers:the liquid storage chamber,mixing chamber,toxicant exposure chamber,and waste liquid receiving chamber.The four chambers were connected by peristaltic pump hoses.The peristaltic pumps were employed to ensure unidirectional and constant speed trans-mission of liquid between these chambers.According to the preset toxicokinetic parameters such as T1/2a and T1/2,an in vitro simulated one compartment extravascular administration model of lanthanum nitrate was constructed using the device.The content of lanthanum nitrate in the toxicant exposure chamber at different time points was measured using inductively coupled plasma mass spectrometry.The concentration-time curves of lanthanum nitrate were analyzed using PKsolver and GraphPad Prism 8.0 software.The constructed in vitro simulated one compartment extravascular administration model was evaluated by comparing the measured and theoretical values of toxicokinetic parameters.HepG2 cells were treated with lanthanum nitrate in the in vitro simulated one compartment extravascular administration model and classic in vitro administration model,respectively,and cell death was measured using the Hoechst 33342/propidium iodide staining method.RESULTS Within the Cmax range of 3.91-1 000.00 μmol·L-1,the measured concentration-time curves of lanthanum nitrate in the toxicant expo-sure chamber almost conformed with the corresponding calculated theoretical curves(the correlation coefficients were all>0.998 0).The measured values of toxicokinetic parameters,including Ke,T1/2,Ka,T1/2a,Tmax,Cmax,CL and AUC0-∞,were close to the corresponding theoretical values.The fitting coeffi-cients(R2)of the concentration-time curves for each experimental group were all>0.990 0,which was consistent with one compartment model for extravascular administration.In the simulated one compart-ment extravascular administration model,no significant death of HepG2 cells was observed in any lanthanum nitrate dose group.In the classic in vitro administration model,the cell death rate of the 0.500 mmol·L-1 lanthanum nitrate group was higher than that of the solvent control group,but no significant cell death was observed in the 0.119 mmol·L-1 group or 0.243 mmol·L-1 group.When Cmax or Cadministration was 0.500 mmol·L-1,classic in vitro administration induced a higher cell death rate than simulated one compart-ment extravascular administration.However,there was no statistically significant difference in lanthanum nitrate induced HepG2 cell death between the two administration models when the AUC was equal.CONCLUSION The device designed in this study can be used to in vitro simulate one compartment extravascular administration,making in vitro toxicity testing more similar to in vivo scenarios,and providing data for optimizing administration methods of in vitro toxicity testing.There are differences in lanthanum nitrate induced HepG2 cell death between simulated one compartment extravascular administration and classic in vitro administration,indicating that different in vitro exposure modes can affect toxicity.

With the rapid development of competitive sports, the incidence of anterior cruciate ligament (ACL) injury is on the rise. Such injuries may shorten athletes′ career and lead to other long-term adverse consequences. Although athletes generally recover well after ACL reconstruction, many still struggle to return to their pre-injury performance levels. Advances in the understanding of ACL anatomy and injury mechanisms, along with the evolution of surgical techniques and rehabilitation methods, have provided more individualized and tailored options for athletes following ACL injuries. However, there is currently no consensus in China regarding surgical and rehabilitation strategies for competitive athletes aiming to return to sports after ACL injuries. To this end, the Sports Medicine Committee of the Chinese Research Hospital Association and the Editorial Board of the Chinese Journal of Trauma jointly formulated the Expert consensus on surgical treatment and rehabilitation for competitive sports athletes returning to sports after anterior cruciate ligament injury ( version 2025), and presented 14 recommendations covering surgical indications, preoperative rehabilitation, surgical timing, surgical strategies and postoperative rehabilitation strategies, aiming to improve the surgical treatment and rehabilitation system for ACL injuries in competitive athletes and facilitate their return to high-level sports performance after injury.

Objective:To investigate the treatment strategies for vesicovaginal fistula（VVF）in women following cervical cancer radiotherapy.Methods:A retrospective analysis was performed on the clinical data of 33 female patients with post-radiotherapy VVF after cervical cancer treatment at Shanghai Sixth People’s Hospital between January 2020 and June 2024. The patients were categorized into three groups based on surgical approaches：Group A（11 patients）：Underwent prone-position VVF repair. Mean age：（50.0±9.6）years；mean radiotherapy sessions：（22.6±2.2）. All had simple VVF without concurrent intestinal or surrounding soft-tissue fistulas. Among them，1 patient previously received laparoscopic VVF repair，1 transvaginal VVF repair，and 2 gracilis muscle flap packing for VVF repair. One month prior to surgery，the average daily usage of urine pads was 16.7（12.8，25.7）pieces，and the quality of life（QOL）score stood at 4.0（4.0，5.0）points. Preoperative cystoscopy revealed that 8 cases had fistulas located in the trigonal region of the bladder，while 3 cases had fistulas on the posterior bladder wall. The diameter of the fistula openings，measured under a microscope，was 1.2（0.8，1.6）cm. Based on the Goh classification criteria for vesicovaginal fistulas，this group included 3 cases of type 1，4 cases of type 2，2 cases of type 3，and 2 cases of type 4；7 cases of type A and 4 cases of type B；as well as 3 cases of typeⅠ，7 cases of type Ⅱ，and 1 case of type Ⅲ.Group B（20 patients）：Underwent gracilis muscle flap packing for VVF repair. Mean age：（58.6±8.8）years；mean radiotherapy sessions：（29.8±3.9）. Three patients had concurrent rectovaginal fistulas and received colostomy for fecal diversion. History of previous interventions：3 had laparoscopic VVF repair，4 transvaginal VVF repair，and 1 both transvaginal and laparoscopic VVF repair. One month prior to surgery，the average daily usage of urine pads was 19.7（15.8，27.7）pieces，and the QOL score stood at 5.0（5.0，6.0）points. Preoperative cystoscopy revealed that 13 cases had fistulas located in the trigonal region of the bladder，while 7 cases had fistulas on the posterior bladder wall. The diameter of the fistula openings，measured under a microscope，was 1.8（1.0，3.2）cm. Based on the Goh classification criteria for vesicovaginal fistulas，this group included 4 cases of type 1，9 cases of type 2，3 cases of type 3，and 4 cases of type 4；6 cases of type A，11 cases of type B and 3 cases of type C；as well as 1 cases of type Ⅱ，and 19 case of type Ⅲ. Group C（2 patients）：Underwent ureterocutaneous diversion. Ages：67 and 73 years；radiotherapy sessions：51 and 60，respectively. Both had concurrent rectovaginal fistulas and bladder soft-tissue fistulas. The patient presented with recurrent thigh abscesses accompanied by fever. One month prior to surgery，the daily usage of urine pads was 29 and 23 pieces，respectively，and the QOL score was 6 points. Cystoscopic examination revealed that the vesicovaginal fistulas were located in the trigone of the bladder，with diameters of 3 cm and 4 cm，respectively. Additionally，partial defects were noted in the ventral wall of the urethra，while no bladder soft tissue fistulas were detected. According to the Goh classification for vesicovaginal fistulas，both cases were categorized as type 4，type C，and type Ⅲ. For Groups A and B，urinary catheters were indwelled for 3 weeks postoperatively，then removed to assess spontaneous urination and incontinence. QOL was evaluated，with a minimum 6-month follow-up. For confirmed postoperative VVF recurrence，re-repair was performed 3?6 months later based on patient preference. For Group C，double-J stents were placed in the ureters，and stoma bags were applied 3 days postoperatively. Stents were replaced every 1?2 months，with QOL assessment. Successful fistula repair in Groups A and B was defined as the absence of vaginal leakage confirmed by cystoscopy after six months of the procedure with no vaginal leakage. For Group C，surgical success was determined by the resolution of perineal urinary leakage and improvement in QOL.Results:All 33 patients completed surgery successfully. Group A：Follow-up duration：16.3（9.6，24.6）months. Surgical repair succeeded in 7 patients，with unobstructed spontaneous urination and no vaginal incontinence. Four patients had VVF recurrence：2 refused further treatment，and 2 underwent repeat gracilis muscle flap packing. One was successfully repaired，while one recurrence case refused further treatment. Group B：Follow-up duration：17.0（9.5，24.8）months（8?32 months）. Thirteen patients restored spontaneous urination without recurrence. Seven had recurrence：5 refused further surgery，and 2 underwent re-repair. One repair succeeded without incontinence，while one recurrence case refused treatment. Group C：Follow-up durations were 6 and 22 months. Perineum remained dry without incontinence（no urine pads needed），and no recurrence of thigh soft-tissue redness/infection occurred. QOL scores were 2 and 3，respectively.Conclusions:Post-radiotherapy VVF in women after cervical cancer presents complex and variable conditions. The primary goal of treatment should be to improve patients’ quality of life. Treatment approaches should be selected based on the complexity of urinary fistulas and local tissue conditions. In general，patients who are younger，have received lower doses of radiation therapy，present with smaller fistula diameters，have well-vascularized and elastic perifistular tissues，and have no concurrent tissue fistulas are candidates for prone-position VVF repair. Patients who do not meet the criteria for transvaginal repair，have a history of at least two previous repair attempts，or have concurrent vaginorectal fistulas require gracilis muscle flap packing for VVF repair. Patients with three or more types of concurrent tissue fistulas，extensive pale and inelastic perifistular tissues，and who are not amenable to repair surgery undergo ureterocutaneous diversion.

Objective To investigate the effects and underlying mechanisms of microRNA (miR)-34a on isoflurane anesthesia-induced cognitive dysfunction in aged rats. Methods Forty rats at 20 months of age were randomly divided into control (Con) group, model group, miR-34a inhibitor group and miR-34a mimics group, with 10 rats in each group. Rats in the miR-34a inhibitor and miR-34a mimics groups received a tail vein injection of 100 nmoL/kg of the corresponding drug, while those in the Con and model groups received an equal volume of saline, once daily for 5 consecutive days. At the 6th day, all groups except the Con group underwent a single 6-hour isoflurane anesthesia to establish a postoperative cognitive dysfunction (POCD) model. Twelve hours after modeling, the Morris water maze test was used to assess the escape latency and time spent in the target quadrant. Immunofluorescence staining was performed to observe the positive expression rate of ionized calcium-binding adapter molecule 1 (Iba-1) in the hippocampal tissue. Real-time quantitative polymerase chain reaction (qRT-PCR) was used to measure the relative expression levels of miR-34a, B-cell lymphoma-2 (Bcl-2) and Bcl-2-associated X-protein (Bax) mRNA in the hippocampal tissue. Enzyme-linked immunosorbent assay (ELISA) was conducted to detect serum levels of interleukin-6 (IL-6), interleukin-1β (IL-1β), reactive oxygen species (ROS) and glutathione peroxidase (GSH-Px), as well as the content of glutamate (Glu), Ca²⁺ and N-methyl-D-aspartate receptor 2B (NMDAR2B) in the hippocampal tissue. Western blotting was used to determine the relative expression levels of calcium-calmodulin-dependent protein kinase Ⅱ (CaMKⅡ), phosphorylated CaMKⅡ (pCaMKⅡ), cyclophosphoadenosine effector-binding protein (CREB), and phosphorylated CREB (pCREB) in the hippocampal tissue. Results Compared with the Con group, the Model group exhibited significantly prolonged escape latency, elevated serum levels of IL-6 and IL-1β and ROS, as well as increased positive expression rate of Iba-1, relative expression levels of miR-34a and Bax mRNA, contents of Glu, Ca²⁺ and NMDAR2B in the hippocampal tissue; in contrast, the time spent in the target quadrant, serum GSH-Px levels, Bcl-2 mRNA relative expression levels, Bcl-2/Bax, as well as pCaMKⅡ/CaMKⅡ and pCREB/CREB in the hippocampal tissue were significantly reduced (P < 0.05). Downregulation of miR-34a expression shortened the escape latency and decreased serum levels of IL-6, IL-1β and ROS, as well as Iba-1 positive expression rate, relative expression levels of miR-34a and Bax mRNA, Glu, Ca²⁺ and NMDAR2B content in the hippocampal tissue (P < 0.05). It also extended the time spent in the target quadrant and increased serum GSH-Px levels, Bcl-2 mRNA expression levels, Bcl-2/Bax, as well as pCaMKⅡ/CaMKⅡ and pCREB/CREB in the hippocampal tissue (P < 0.05). Upregulation of miR-34a expression promoted abnormal activation of microglia, inflammation, oxidative stress and apoptosis, inhibited the activation of the CaMKⅡ/CREB signaling pathway, and exacerbated cognitive dysfunction in the model rats. Conclusion MiR-34a is highly expressed in POCD in aged rats. Inhibition of miR-34a expression can improve isoflurane anesthesia-induced cognitive dysfunction in aged rats by activating the CaMKⅡ/CREB signaling pathway.