北京大学学报（医学版）最新文献

Objective: To summarize the surgical strategies and to evaluate the clinical outcomes of upper urinary tract reconstruction in patients with stone-related ureteral strictures.

Methods: This retrospective study included 71 patients diagnosed with ureteral strictures secondary to urinary stones who underwent upper urinary tract reconstructive surgery at Peking University First Hospital between March 2014 and November 2023. Patient data were collected, including demographic characteristics, clinical presentation, laboratory results, imaging findings, surgical procedures, and follow-up outcomes. Ureteral strictures were classified according to anatomical location into upper, middle, lower, or multiple segments. Surgical procedures were carried out depending on the stricture characteristics. Surgical success was defined as resolution or improvement of clinical symptoms, radiographic improvement or stabilization of hydronephrosis, and maintenance of normal and stable renal function.

Results: Among the 71 patients, 36 (50.7%) had strictures in the upper ureter, 9 (12.7%) in the middle ureter, 15 (21.1%) in the lower ureter, and 11 (15.5%) had multifocal ureteral strictures. The median stricture length was 5.0 cm (interquartile range: 3.0-15.0 cm). Surgical approach selection was individualized based on the location and extent of the stricture. For upper ureteral strictures, the most frequently employed techniques were oral mucosal graft ureteroplasty (13/36, 36.1%) and appendiceal flap ureteroplasty (8/36, 22.2%). Other options included ureteroureterostomy and ileal ureter replacement for longer or more complex strictures. In middle ureteral strictures, treatment was stratified by length: balloon dilation (1/9, 11.1%) and ureteroureterostomy (1/9, 11.1%) were applied in shorter strictures, while oral mucosal graft ureteroplasty (3/9, 33.3%) and ileal ureter replacement (4/9, 44.4%) were reserved for longer segments. For lower ureteral strictures, ureteral reimplantation into the bladder was the most common approach (10/15, 66.7%), often combined with a psoas hitch or Boari flap when necessary. All the patients with multiple segmental strictures underwent ileal ureter replacement due to the extensive nature of the disease. The median follow-up period was 14.2 months (range: 6.1-107.1 months). During follow-up, 69 of 71 patients (97.2%) achieved surgical success.

Conclusion: Stone-related ureteral strictures present with considerable heterogeneity in terms of anatomical location, length, and complexity. Careful preoperative evaluation and individualized surgical planning are critical to successful reconstruction. With appropriate selection of surgical methods, favorable long-term clinical outcomes can be achieved in the majority of patients.

Objective: To investigate the safety and feasibility of the domestic single-port serpentine-arm robotic surgical system for pyeloplasty in children with congenital ureteropelvic junction obstruction (UPJO).

Methods: Data of UPJO patients who underwent pyeloplasty using a domestic single-port serpentine-arm robotic surgical system (Beijing Surgerii Robotics Co., Ltd.) in Beijing Children's Hospital from November 2023 to February 2024 were retrospectively collected. The patients who were not receiving surgical treatment for the first time, had hydronephrosis caused by other reasons (such as ureterovesical junction obstruction, posterior urethral valve, urinary tract stones, vesicoureteral reflux, ureterocele, etc.), had other urinary tract malformations (such as duplicated kidneys, congenital renal dysplasia, etc.), had severe atrophy of the affected kidney, severe urinary tract infection or severe renal insufficiency were excluded. All the surgeries were performed through the umbilicus and abdominal cavity, and the operation time, number of intraoperative incisions, incision size, intraoperative blood loss, and peri-operative complications were recorded. Statistical analysis was performed to compare changes in the anteroposterior pelvic diameter (APD) and renal cortical thickness before surgery and 6 months postoperatively.

Results: A total of 10 patients were included (8 males and 2 females), with an average age of (10.20±3.12) years. Nine patients were on the left side and one patient was on the right side. The average height was (142.0±17.8) cm and the average weight was (37.6±17.9) kg. All the patients underwent surgery using the domestic single-port robotic surgery system, and no patient was converted to open pyeloplasty. The total operation time was (237±96) min, and the operation time on the operating table was (162.0±69.3) min. The intraoperative blood loss was 5.00 (2.25, 5.00) mL. No complications, such as bleeding, urine extravasation, fever, and poor wound healing occurred during the perioperative period. Compared with the preoperative measurements, the APD was significantly shortened postoperatively (P=0.005), and the renal cortical thickness significantly increased (P=0.011).

Conclusion: The domestic single-port serpentine arm robotic surgical system is safe and feasible for UPJO pyeloplasty in children, with good surgical results, and can be promoted and applied in most domestic medical centers.

Objective: To evaluate the safety and efficacy of a dual-endoscopic technique combining laparoscopy/robot-assisted laparoscopy with disposable flexible ureteroscopy for intraoperative localization and reconstruction in complex ureteral strictures.

Methods: A retrospective analysis was conducted on 21 patients with complex ureteral strictures (stenosis length ≥2 cm, multiple strictures, or iatrogenic strictures, or radiation-induced strictures) treated at Peking University People' s Hospital between January 2023 and November 2024. All the patients underwent dual-endoscopic procedures using laparoscopy (n=17) or da Vinci robotic-assisted laparoscopy (n=4) combined with disposable flexible ureteroscopy. Preoperative evaluation included contrast-enhanced CT urography and diuretic renography. Intra-operatively, stricture localization was achieved by synchronizing laparoscopic light sources with ureteroscopic visualization. Surgical positions were optimized: non-split-leg oblique supine position for mid-upper strictures and lithotomy position for mid-lower strictures. Reconstruction strategies (lingual mucosa graft, bladder flap augmentation, or primary anastomosis) were selected based on stricture length and tension. Postoperative outcomes were assessed via symptom resolution, hydronephrosis improvement (ultrasonographic renal pelvis diameter), and stent-free patency.

Results: The cohort included 10 males and 11 females [mean age (44.1±13.3) years]. Etiologies included lithogenic strictures (71.4%, 15/21), post-gynecologic surgery injury (4.8%), radiation-induced fibrosis (4.8%), and congenital factors (19.0%). Intraoperative findings revealed discrepancies in stricture localization compared with pre-operative imaging in 52.4% (11/21) of cases, necessitating extended resection or modified reconstruction. Mean stricture length was (4.81±4.33) cm. Postoperative complications included transient urinary leakage (1 case) and secondary ureteral obstruction due to stone migration (1 case), both resolved without sequelae. At a mean follow-up of (10.76±6.81) months (range 2-21), hydronephrosis significantly improved in all the patients (100% efficacy), with no recurrence of strictures or symptom recurrence.

Conclusion: The dual-endoscopic technique enhances intraoperative precision in complex ureteral stricture management by integrating real-time luminal visualization with extraluminal anatomical guidance. This approach minimizes excessive resection of healthy ureter, optimizes reconstruction strategies, and reduces postoperative recurrence. The modified positioning protocol further improves ergonomic efficiency, making it a reliable and adaptable option for challenging ureteral pathologies.

Objective: To review and summarize the experience of robot-assisted laparoscopic transplant nephrectomy, share the surgical steps and technical key points, and provide a reference for clinical practice.

Methods: A retrospective analysis was conducted on the perioperative data of 5 patients who underwent robot-assisted laparoscopic donor nephrectomy at Peking University Third Hospital from August 2023 to December 2024. The surgical steps and key points were summarized. The continuous variables were described by medians(ranges).

Results: A total of 5 patients were included in the analysis, of whom 2 were male and 3 were female. The median age of the patients was 37 (31-68) years. The median time from kidney transplantation to donor nephrectomy was 10 (3-22) years. The indications for donor nephrectomy included recurrent hematuria, abdominal pain, malignant tumor of the transplanted kidney, and recurrent infection with hydronephrosis of the transplanted kidney. The excised transplanted kidneys from all the 5 patients had a single renal artery and a single renal vein. The median operation time was 212 (145-351) min, the median blood loss was 300 (20-500) mL, and the median post-operative hospital stay was 7 (4-25) days. Only 1 patient experienced intraoperative complications, who experienced an external iliac artery injury during the operation and underwent suture repair. No patient died during the perioperative period. Postoperative pathological results showed that 3 patients had end-stage non-functional kidneys, 1 patient had BK virus-associated urothelial carcinoma, and 1 patient had chronic pyelonephritis with renal parenchymal atrophy.

Conclusion: Robot-assisted laparoscopic transplant nephrectomy as a new surgical approach is feasible and safe. Compared with traditional open transplant nephrectomy, its advantage lies in the ability to directly observe and prioritize the management of the renal pedicle of the transplanted kidney, while completely freeing and removing the transplanted kidney outside the renal capsule. With the continuous accumulation of experience, this surgical technique is expected to become a powerful alternative to traditional open transplant nephrectomy.

Objective: To analyze the clinical features associated with pelvic lymph node metastasis (PLNM) in prostate cancer and to construct a preoperative prediction model for PLNM, thereby reducing unnecessary extended pelvic lymph node dissection (ePLND).

Methods: Based on predefined inclusion and exclusion criteria, 344 patients who underwent radical prostatectomy and ePLND at the First Affiliated Hospital of Zhengzhou University between 2014 and 2024 were retrospectively enrolled, among whom, 77 patients (22.4%) were pathologically confirmed to have lymph node-positive disease. The clinical characteristics, MRI reports, and pathological results were collected. The data were then randomly divi-ded into a training cohort (241 cases, 70%) and a validation cohort (103 cases, 30%). Univariate and multivariate Logistic regression analysis were employed to construct a preoperative prediction model for PLNM.

Results: Univariate Logistic regression analysis revealed that total prostate specific antigen (tPSA) (P=0.021), free prostate specific antigen (fPSA) (P=0.002), fPSA to tPSA ratio (fPSA/tPSA) (P=0.011), percentage of positive biopsy cores (P < 0.001), prostate imaging reporting and data system (PI-RADS) score (P=0.004), biopsy Gleason score ≥8 (P=0.005), clinical T stage (P < 0.001), and MRI-indicated lymph node involvement (MRI-LNI) (P < 0.001) were significant predictors of PLNM. Multivariate Logistic regression analysis demonstrated that the percentage of positive biopsy cores (OR=91.24, 95%CI: 13.34-968.68), PI-RADS score (OR=7.64, 95%CI: 1.78-138.06), and MRI-LNI (OR=4.67, 95%CI: 1.74-13.24) were independent risk factors for PLNM. And a novel nomogram for predicting PLNM was developed by integrating all these three variables. Compared with the individual predictors: percentage of positive biopsy cores [area under curve (AUC)=0.806], PI-RADS score (AUC=0.679), and MRI-LNI (AUC=0.768), the multivariate model incorporating all three variables demonstrated significantly superior predictive performance (AUC=0.883). Consistently, calibration curves and decision curve analyses confirmed that the multivariable model had high predictive accuracy and provided significant net clinical benefit relative to single-variable models. And using a cutoff of 6%, the multiparameter model missed only approximately 5.2% of PLNM cases (4/77), while reducing approximately 53% of ePLND procedures (139/267), demonstrating favorable predictive efficacy.

Conclusion: Percentage of positive biopsy cores, PI-RADS score and MRI-LNI are independent risk factors for PLNM. The constructed multivariate model significantly improves predictive efficacy, offering a valuable tool to guide clinical decisions on ePLND.

Objective: To analyze and compare the interfractional setup errors between two body positioning fixation methods (lithotomy position with carbon fiber full-body fixation frame vs. conventional carbon fiber body fixation frame combined with thermoplastic membrane) in radical radiotherapy for prostate cancer, and to calculate the clinical target volume (CTV) to planning target volume (PTV) margin (MPTV) for both methods to optimize immobilization techniques and radiotherapy workflows.

Methods: A retrospective analysis was conducted on 37 consecutive patients who underwent radical prostate radiotherapy at Peking University First Hospital between August 2021 and March 2023. The patients were divided into two groups based on the immobilization method: Group A (18 patients, 450 CBCT image sets) used a carbon fiber whole-body fixator in the lithotomy position, while Group B (19 patients, 461 CBCT image sets) used a conventional carbon fiber fixator combined with a thermoplastic mask. All the patients underwent daily cone-beam computed tomography (CBCT) image guidance. Bone registration combined with manual registration was used to obtain the setup error data in the left-right (X), cranio-caudal (Y) and anterior-posterior (Z) directions. The positioning errors of the two groups were compared by using the independent sample t-test, the Mann-Whitney U test and the chi-square test. The average positioning error, systematic positioning error (Σ) and random positioning error (δ) were calculated, and the CTV-PTV extension distance was calculated by using the (MPTV=2.5Σ+0.7δ).

Results: The analysis of the setup errors in the three-dimensional direction showed significant differences between the two groups (all P < 0.01). Specifically, the median (quartile) absolute values of the errors in the X, Y, and Z directions of group A were [0.40 (0.20, 0.70) cm, 0.50 (0.30, 0.80) cm, and 0.35 (0.20, 0.60) cm], respectively. In group B, the corresponding values were significantly reduced to [0.20 (0.10, 0.40) cm, 0.40 (0.20, 0.70) cm and 0.20 (0.10, 0.40) cm]. The results of Mann-Whitney U test showed that the differences in each direction were highly statistically significant (X: z=-6.86; Y: z=-2.76; Z: z=-5.71). The cumulative distribution ratio of the setup error displacement within 0.5 cm in the X, Y, and Z directions in group A and group B were 297 (66.0%) and 408 (88.5%) (P < 0.01), 250 (55.6%) and 285 (61.8%) (P=0.055), 308 (68.4%) and 391 (84.8%) (P < 0.01), respectively. The CTV-PTV margins in three directions were X 0.66 cm in group A and 0.35 cm in group B; Y 0.67 cm and 0.45 cm; Z 0.54 cm and 0.42 cm.

Conclusion: Conventional carbon fiber human body fixator combined

Objective: To evaluate the technical feasibility and perioperative safety of pyeloplasty assisted by the Carina^TM modular laparoscopic surgical robotic system in patients with ureteropelvic junction obstruction (UPJO).

Methods: From November to December 2024, five consecutive patients diagnosed with UPJO underwent robot-assisted pyeloplasty using the Carina^TM modular laparoscopic surgical system at Peking University First Hospital. Data on patient demographics, intraoperative parameters (including docking time, console time, and estimated blood loss), perioperative outcomes, follow-up results, and surgeons' subjective evaluations of system performance were prospectively collected. Descriptive statistics were used; continuous variables were presented as median (range), and categorical variables as frequency and percentage.

Results: The cohort included four females and one male. All the patients successfully completed the robotic procedure without conversion to open or conventional laparoscopic surgery. The median age was 32 years (24-37 years), and the median body mass index was 21.6 kg/m² (15.8-27.3 kg/m²). The median docking time was 8 min (3-12 min), and the median console time was 91 min (71-125 min). Intraoperative blood loss was uniformly 20 mL. The median postoperative drainage duration was 3 d (0-4 d), and the median length of hospital stay was 4 d (4-9 d). No Clavien-Dindo grade Ⅲ or higher complications occurred. All the patients had their double-J stents removed at 2 months postoperatively, and pain in the ipsilateral flank, reported preoperatively by all the five patients, was alleviated. The subjective surgical success rate was 100%. Surgeons reported stable system performance throughout all the procedures, with no instances of mechanical arm interference or visual drift affecting surgical fluency.

Conclusion: Preliminary findings indicate that pyeloplasty using the domestically deve-loped Carina^TM modular laparoscopic robotic system is technically feasible and perioperatively safe for the treatment of UPJO.

Objective: To compare the differences in breastfeeding rates and the incidence of clinical complications in very/extremely low birth weight infants with and without the use of donor milk banks.

Methods: Before and after the establishment of the donor milk bank, a total of 279 very/extremely low birth weight infants who were hospitalized in neonatal intensive care unit in a tertiary hospital in Beijing were selected. In the study, 136 infants who did not receive donated breast-feeding were included in control group and 143 infants who received donated breast-feeding were included in observation group. The clinical data of mothers and their infants were collected. The mother' s information included gestational age, maternal comorbidities, and mode of delivery. Infant information includes gender, weight, gestational age, duration of breastfeeding, total enteral feeding time, hospitalization time and incidence of complications (feeding intolerance, necrotizing enterocolitis, retinopathy of prematurity).

Results: The maternal ages were (33.5 ± 4.2) years in the observation group and (32.5 ± 3.9) years in the control group. Cesareans were performed in 95 cases (70.4%) and 81 cases (66.9%), respectively. The gestational ages of preterm infants were (29.2 ± 2.1) weeks and (29.1 ± 2.2) weeks, with birth weights of (1 140.5 ± 247.1) g and (1 169.4 ± 228.6) g, respectively. Newborn boys accounted for 72 cases (50.3%) in the observation group and 63 cases (46.3%) in the control group. No statistically significant differences were found in baseline characteristics between the two groups (all P > 0.05). After the use of donor milk banks, the rate of exclusive breastfeeding in very/low birth weight infants increased from 3.1% to 10.5% (χ²=5.778, P=0.016) during hospitalization, the time to full enteral feeding was shortened from 13 d to 10 d (Z=-4.567, P < 0.001), the first breastfeeding time was shortened from the third day of admission to the first day of admission (Z= -11.812, P < 0.001), the first breastfeeding of mother' s own milk was extended from the third day of admission to the fourth day of admission (Z=-4.652, P < 0.001), and the incidence of feeding intolerance during hospitalization was reduced from 34.0% to 10.0% (χ²=17.015, P < 0.001). There were no significant differences in the incidence of necrotizing enterocolitis, late-onset sepsis, retinopathy of prematurity and total length of hospital stay (P>0.05).

Conclusion: The use of donor milk bank can improve the breastfeeding rate, shorten the time to first breastfeeding, and reduce the incidence of feeding intolerance in very/extremely low birth weight infants, which provides a reference for the clinical treatment of very/extremely low birth weight infants.

This case report describes the diagnostic and therapeutic management of a 67-year-old female with a 40-year history of Sjögren disease (SjD) who was hospitalized for evaluation of recurrent fever lasting over one month. The patient' s initial diagnosis of SjD was established four decades earlier based on clinical manifestations, serological findings, and evidence of glandular damage. Her clinical presentation included recurrent parotid gland enlargement accompanied by sicca symptoms, notably persistent xerostomia and xerophthalmia, followed by progressive dental caries. Serological studies demonstrated positivity for antinuclear antibodies, anti-SSA/Ro, and anti-α-fodrin antibodies. Objective assessments confirmed significant ocular involvement (Schirmer' s test ≤5 mm/5 min) and pulmonary interstitial changes on chest CT, consistent with the 2016 American College of Rheumatology and European League Against Rheumatism (ACR/EULAR) classification criteria for SjD. The patient' s condition remained stable under low-dose corticosteroids and disease-modifying anti-rheumatic drugs (DMARDs) until the recent onset of prolonged fever, necessitating evaluation for fever of unknown origin. Differential diagnoses considered disease flare, infection, and malignancy. The European Sjögren' s Syndrome Disease Activity Index (ESSDAI) score was 5 points, indicating moderate systemic disease activity. Initial laboratory investigations revealed no evidence of infection, and empirical anti-infective therapy proved ineffective. Notably, despite the absence of lymphadenopathy, laboratory findings including borderline positive IgM λ M-protein, elevated lactate dehydrogenase, hyperferritinemia, and increased β2-microglobulin levels raised suspicion for lymphoproliferative disorders, given the established association between SjD and lymphoma. Bone marrow aspiration showed no significant abnormalities, but PET/CT imaging detected hypermetabolic lesions in the left breast and right distal femur, suggesting potential malignancy. Subsequent histopathological examination of the breast lesion confirmed non-Hodgkin' s lymphoma (NHL), specifically diffuse large B-cell lymphoma (DLBCL) of the germinal center B-cell (GCB) subtype. Treatment with R-CHOP chemotherapy (rituximab, cyclophosphamide, doxorubicin, vincristine, and prednisone) induced complete metabolic remission after three cycles. However, she subsequently developed treatment-related complications, including myelosuppression and pulmonary infection. This case underscores the importance of maintaining a high index of suspicion for atypical site involvement in SjD patients, particularly when lymphoma risk factors are present. Comprehensive differential diagnosis should include lymphoma and other malignancies, and the diagnostic value of PET/CT and histopathological examination in disease evaluation is emphasized. SjD complicated by breast lymphoma is exceptionally rare, and its pathogenesis may involve lymphocytic inf