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.

【Objective】 To explore the learning curve of single-surgeon robot-assisted laparoscopic radical prostatectomy (RARP), which provides a reference for physicians who intend to carry out RARP. 【Methods】 The clinical data of 65 prostate cancer patients who underwent RARP in our hospital during Sep.2022 and Dec.2023 were retrospectively analyzed.The patients’ median age was 67.5(58.1-82.4) years, median total prostate-specific antigen (PSA) was 15.6 (6.7-98.4) ng/mL, median body mass index (BMI) was 20.8(17.4-27.3) and preoperative clinical stage of tumor was T2aN0M0-T3bN1M0.The cumulative sum (CUSUM) method was used to fit the learning curves of machine installation time and operation time.According to the inflection points, the learning curves were divided into different learning stages, and the clinical data of patients at different learning stages were compared. 【Results】 The learning curve of RARP was 12 cases.The 65 cases were divided into three stages: 1st-12th cases in the learning stage, 13rd-43rd cases in the mastery stage, and 44th-65th cases in the proficiency stage.With the increase of the number of surgical cases, the median operation time [191(100-360) min vs. 116(83-165) min vs. 90(75-105) min] and median intraoperative blood loss [403(180-900) mL vs. 236(180-305) mL vs. 94(30-200) mL] in the three stages showed a gradual downward trend (P<0.05).The median machines installation time of the learning stage was significantly longer than that in the mastery stage and the proficiency stage [25(21-28) min vs. 12(11-15) min vs. 12(11-14) min] (P<0.05).The positive surgical marginrate (PSM) in the learning stage was significantly higher than that in the mastery stage and proficiency stage (41.7% vs.22.6% vs.22.7%) (P<0.05). 【Conclusion】 For surgeons with rich experience in traditional laparoscopic surgery, the learning curve of RARP is about 12 cases, and after 43 cases, the operation time and intraoperative blood loss can be further reduced.

ObjectiveTo investigate the efficacy and safety of N-acetylcysteine （NAC） in the treatment of severe alcoholic hepatitis （SAH）， and to provide a basis for clinical medication for SAH. MethodsA prospective randomized controlled trial was conducted among 172 SAH patients with a Maddrey discriminant function score of >32 points who were recruited by The Fifth Medical Center of Chinese PLA General Hospital from June 2015 to June 2018， and these patients were divided into NAC group with 84 patients and control group with 86 patients. NAC （8 g/day， 28 days） was assessed in terms of its safety in SAH patients， its impact on 28-day biochemical parameters， and its role in improving 28- and 180-day survival rates. A further analysis was performed to investigate the effect of NAC on the 28- and 180-day survival rates of SAH patients with acute-on-chronic liver failure （ACLF-SAH patients） and those without acute-on-chronic liver failure （non-ACLF-SAH patients）. The independent-samples t test was used for comparison of normally distributed continuous data between two groups， and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups. The Kaplan-Meier method was used to plot survival curves， and the Log-rank test was used for comparison of survival curves. Univariate and multivariate Cox proportional-hazards regression model analyses were used to investigate independent influencing factors. ResultsNo serious adverse events were observed during NAC treatment， suggesting that NAC had a good safety profile. Compared with the control group， NAC did not significantly improve the 28-day biochemical parameters （all P>0.05） and survival rate of SAH patients （P=0.081）， but it could improve the 180-day survival rate of SAH patients （67.4% vs 81.0%， χ²=4.280， P=0.039）. NAC did not improve the 28- and 180-day survival rates of ACLF-SAH patients （both P>0.05）； NAC did not improve the 28-day survival rate of non-ACLF-SAH patients （P>0.05）， but it could improve the 180-day survival rate of these patients （68.4% vs 88.9%， χ²=4.883， P=0.027）. The multivariate Cox regression survival analysis showed that NAC treatment （hazard ratio ［HR］=2.530， 95% confidence interval ［CI］： 1.334‍ ‍— 4.796， P=0.004，）， Maddrey discriminant function score （HR=3.852， 95%CI： 2.032 — 7.304， P<0.001）， and serum sodium level （HR=1.948， 95%CI： 1.079‍ ‍—‍ ‍3.517， P=0.027） were independent influencing factors for 180-day survival rate in SAH patients. ConclusionNAC has a good safety profile in the treatment of SAH and can improve the 180-day survival rate of SAH patients， and in particular， non-ACLF-SAH patients can benefit from NAC treatment in terms of middle- and long-term survival rates.

Anterior communicating artery (ACoA) aneurysms may rarely lead to oculomotor nerve palsy. We present here interesting cases in which isolated unilateral adduction paresis mimicking internuclear ophthalmoplegia (INO) was one of the symptoms of suspicious impending ruptured aneurysm of the ACoA. Careful neurologic examination is crucial for early discrimination with INO and oculomotor palsy.