Thoracoscopic Anatomical Sublobar Resection Including Subsegmentectomy for Non-Small Cell Lung Cancer.

BACKGROUND: Among anatomical sublobar resection techniques for non-small cell lung cancer (NSCLC), the clinical benefit of subsegmentectomy remains unclear. We investigated whether anatomical sublobar resection including subsegmentectomy-segmental resection with subsegmental additional resection or subsegmental resection alone-is an effective and feasible surgical procedure for NSCLC. METHODS: We retrospectively reviewed data of 285 patients with clinical stage I NSCLC who underwent anatomical sublobar resection at our institution from January 2013 to March 2021 and compared surgical outcomes between patients who underwent anatomical sublobar resection including (IS; n = 50) and excluding (ES; n = 235) subsegmentectomy. RESULTS: No significant intergroup differences were noted in terms of age, sex, smoking, comorbidities, tumor size or location, consolidation tumor ratio, and preoperative pulmonary function. The IS group had more preoperative computed tomography-guided markings (34 vs. 15%; p = .004) and smaller resected lung volumes converted to the total subsegment number [3 (2-4) vs. 3 (3-6); p = .02] than the ES group. No significant differences in margin distance [mm, 20 (15-20) vs. 20 (20-20); p = .93], readmission rate (2% vs. 3%; p > .99), and intraoperative (8% vs. 7%; p = .77) or postoperative (8% vs. 10%; p = .80) complication rates were observed, and the 5-year local recurrence-free survival (91% vs. 90%; p = .92) or postoperative pulmonary function change were comparable between both groups. CONCLUSIONS: Although further investigations are required, anatomical sublobar resection including subsegmentectomy for clinical stage I NSCLC could be an acceptable therapeutic option.

Complex video-assisted thoracoscopic surgery lobectomy for locally advanced lung cancer: a prospective feasibility study.

PURPOSE: The limitations regarding indications for video-assisted thoracoscopic surgery lobectomy requiring complex surgery remain unclear. A prospective cohort study was conducted to elucidate the safety and feasibility of complex thoracoscopic lobectomy for patients with locally advanced non-small-cell lung cancer. METHODS: We planned to enroll patients who were suspected of needing thoracoscopic lobectomy or more with complex surgery, including tracheo-bronchoplasty, pulmonary arterioplasty, and combined resection of adjacent organs. Between February 2016 and January 2019, 28 consecutive patients were prospectively enrolled. RESULTS: After excluding 1 patient due to disease progression, 27 patients were included in this study. Three patients underwent thoracoscopic lobectomy without complex surgery. Of the remaining 24 patients, complex thoracoscopic lobectomy was successfully completed in 21 (88%), and the 3 conversions were due to surgery for the great vessels. All 27 patients achieved complete resection. Six patients (22%) suffered grade 2 complications, and the in-hospital, 30-day, and 90-day mortality rates were all 0%. At a median follow-up time of 900 days, the 3-year overall and disease-free survival rates were 75% and 54%, respectively. CONCLUSIONS: Complex thoracoscopic lobectomy was shown to be safe and feasible in select patients with locally advanced non-small-cell lung cancer excluding invasion to the great vessels. CLINICAL REGISTRATION NUMBER: University Hospital Medical Information Network Clinical Trials Registry, 000,019,441 (JAPAN). Institutional Review Board number: 46-15-0003 (accepted at September 7, 2015).

Long-term outcomes of video-assisted thoracoscopic surgery lobectomy vs. thoracotomy lobectomy for stage IA non-small cell lung cancer.

OBJECTIVES: Video-assisted thoracoscopic surgery (VATS) lobectomy is performed widely for patients with clinical stage I non-small cell lung cancer (NSCLC) because of its superior short-term outcomes to those of thoracotomy lobectomy. However, the long-term outcomes of VATS lobectomy vs. thoracotomy lobectomy remain controversial. METHODS: We reviewed the clinical data of 202 consecutive patients who underwent lobectomy for clinical stage IA NSCLC at our institution between January, 2008 and December, 2013. Stage IA NSCLC was confirmed pathologically in 162 of these patients, 60 of whom underwent VATS lobectomy and 102 of whom underwent thoracotomy lobectomy. We compared the perioperative clinical factors and outcomes of these two groups, using a propensity score-matched analysis. RESULTS: In an analysis of 58 matched cases, the VATS group showed less blood loss, a shorter duration of chest tube placement, a shorter postoperative hospital stay, and a lower peak C-reactive protein value, despite a longer operative time. The VATS group also had significantly longer survival than the thoracotomy group [5-year overall survival, 100% vs. 87%, respectively (p = 0.01); 5-year disease-free survival, 100% vs. 86% (p = 0.03)]. CONCLUSIONS: These findings suggest that VATS may have better long-term as well as short-term outcomes than thoracotomy for patients with early-stage NSCLC.

Thymothymectomy with pulmonary partial resection using the subxiphoid approach: how to do it?

An open approach by sternotomy is still selected for locally advanced anterior mediastinal tumors. Technical and instrumental improvements to video-assisted thoracic surgery (VATS) have enabled the treatment of anterior mediastinal tumor in the last decade, and the indications of VATS for an anterior mediastinal tumor are thus expanding. Recently, a single-port thymectomy procedure using the subxiphoid approach has gained popularity worldwide because of its low invasiveness. Improvements to the thoracoscopic instruments and the development of a single-port device are expanding the adoption of single-port VATS in the thoracic surgical field, including resection of anterior mediastinal tumors. We, herein, report a case of thymothymectomy with pulmonary partial resection using the subxiphoid approach. This approach is useful for extended operation for anterior mediastinal tumors and provides favorable results regarding postoperative pain and cosmetic outcomes.

The Subxiphoid Approach Leads to Less Invasive Thoracoscopic Thymectomy Than the Lateral Approach.

OBJECTIVE: Video-assisted thoracic surgery (VATS) is widely used in thoracic surgery. This study investigated the usefulness of the subxiphoid approach in thymectomy using VATS techniques. METHODS: Sixty operations were performed using the lateral approach (n = 46) and subxiphoid approach (n = 14). Using the lateral approach, 39 partial thymectomies (PT), 5 total or subtotal thymectomies (TT), and 2 total or subtotal thymectomies with combined resection of the surrounding organs (or tissues) (CR) were performed. Using the subxiphoid approach, 11 TT and 3 CR were performed. RESULTS: There were 33 females and 27 males, with a mean age of 55 years. The mean maximum tumor diameter was 4.0 cm. The operation time was prolonged according to the volume of thymectomy (PT: 119, TT: 234, CR: 347 min). Additionally, the intraoperative blood loss increased according to the volume of thymectomy (PT: 29, TT: 47, CR: 345 g). To compare the invasiveness of both approaches, we compared 16 TT operations. In the group using the subxiphoid approach, the operation time became shorter (158 vs. 392 min), and the blood loss decreased (5 vs. 135 g) compared with the lateral approach. Regarding laboratory data, white blood cell counts on postoperative day 1 (1POD) (8200 vs. 10,300/µl) and CRP on 1POD and 3POD (2.8 and 2.8 vs. 7.9 and 10.2 mg/dl, respectively) decreased in the subxiphoid approach compared with the lateral approach. CONCLUSIONS: The subxiphoid approach leads to a less invasive operation for anterior mediastinal tumors and extends the indications for VATS for invasive anterior mediastinal tumors.

Expression of vascular endothelial growth factor receptor in thymic epithelial tumors.

Thymic epithelial tumors (TETs) are rare and the major symptoms are not obvious until the tumor progresses to a relatively large size and compresses the surrounding organs. As its growth is aggressive and it metastasizes to distant organs, it is important to find novel effective therapies. Lenvatinib, a vascular endothelial growth factor receptor (VEGFR) inhibitor, is approved as a drug therapy for thymic carcinoma (TC); however, although it is a molecular targeted therapy, there are no obvious predictors of therapeutic efficacy. The present study aimed to assess the association between clinicopathological factors and the protein expression of VEGFR, which is associated with tumor aggressiveness and the efficacy of VEGFR inhibitors. The VEGFR-2 protein expression was evaluated in 144 patients with TETs who underwent surgical resection. The present study assessed whether the expression of VEGFR-2 protein was associated with TET classification and pathological stage, progression-free survival and overall survival (OS). A total of 94 cases (65.2%) were positive for VEGFR-2 protein. The expression of VEGFR-2 was higher in the more aggressive type B3 thymoma and TC (88.5%) than in types A, AB, B1 and B2 thymoma (60.2%). The 5-year OS rate for the overall population was 53.1%. The 5-year OS rates of patients with negative VEGFR-2 staining score values (66.5%) were significantly longer than in patients with positive VEGFR-2 staining score values (42.5%; P=0.000078). Furthermore, the pathological stage was the only factor significantly associated with OS in multivariate analysis. The results of the present study suggest the possibility that the indications for VEGF inhibitor therapy could be extended to type B3 thymoma.

[Video-assisted thoracoscopic extended thymectomy while using the carbon dioxide insufflation].

A 40-year-old woman with generalized myasthenia gravis was scheduled for extended thymectomy. The patient under general anesthesia with double-lumen intubation was placed in the supine position. A sealed 5 mm trocar and 2 sealed 12 mm trocars were inserted through the 3rd, 4th and 5th intercostal space at the both side of the anterior axillary line. Under carbon dioxide insufflations by positive pressure of 7 mmHg, thymus and fat tissue was resected completely. An operation time was 162 minutes, and blood losses during operation were 5 ml. The present method was thought to be safe and useful for conducting extended thymectomy.

A large intrathoracic goiter with tracheal stenosis: Complete resection using a robot-assisted thoracoscopic approach.

Growing intrathoracic goiters may compress surrounding organs and deteriorate the cardiopulmonary function. Treating such cases requires carefully considering how to maintain oxygenation and resect the tumor with minimal invasiveness without complications. We herein report a surgically resected case of a large intrathoracic goiter-compressed trachea extending from the right lower pole of the thyroid gland to the carina. We secured the airway by intubation preparing for extracorporeal membrane oxygenation and successfully performed surgical complete resection using a robot-assisted thoracoscopic and cervical approach. Intrathoracic goiter is a tumor with abundant neovascularity, and the right vagus nerve is displaced in the thoracic cavity, but a robot-assisted thoracoscopic approach using CO2 insufflation improved visualization at the narrow apex area of the thoracic cavity. Robot-assisted thoracoscopic surgery is a useful surgical procedure enabling safe and minimally invasive surgery without recurrent laryngeal nerve palsy or tracheal injury for intrathoracic giant goiters extending into the thoracic cavity.

Prognostic value of systemic inflammatory markers and the nutrition status in thymic epithelial tumors with complete resection.

BACKGROUND: Recent studies have shown that several systemic inflammatory markers and the nutrition status, including the neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), and prognostic nutritional index (PNI), are useful prognostic factors in several malignant tumors. The present study explored the prognostic value of the NLR, MLR, PLR, and PNI in thymic epithelial tumor (TET) patients who underwent complete resection. METHODS: A total of 158 TET patients who underwent complete resection were involved in the analysis. Their NLR, MLR, PLR, and PNI values were obtained from a blood examination within one month before the initiation of treatment. A receiver operating characteristic curve analysis was conducted to determine the optimal cutoff values. RESULTS: The enrolled patients were stratified by cutoffs of 4.35 for the NLR, 0.22 for the MLR, 130.18 for the PLR, and 44.02 for the PNI. A univariate analysis revealed that high-grade malignant TET, including type B2 and B3 thymoma, thymic carcinoma, and thymic neuroendocrine tumor; an advanced Masaoka stage; a high NLR; a high MLR; and a low PNI were significant predictors of a poor disease-free survival (DFS). A multivariate analysis confirmed that an advanced Masaoka stage (HR = 5.5557, p = 0.0007) and a high MLR (HR = 3.3371, p = 0.0264) were independent predictors of a poor DFS. CONCLUSIONS: Our study demonstrated that the pretreatment MLR was an independent predictor of the DFS in patients with TETs who underwent complete resection.

Comparison of the efficacy of novel two covering methods for spontaneous pneumothorax: a multi-institutional study.

OBJECTIVES: The postoperative recurrence rate after thoracoscopic bullectomy for primary spontaneous pneumothorax (PSP) is not satisfactory. This retrospective study was conducted to elucidate an effective technique for improving the postoperative recurrence rate. METHODS: The present study included 373 patients who underwent thoracoscopic bullectomy for PSP at three hospitals from January 2013 to May 2020. We compared the recurrence rate according to two methods that were used to cover the staple line after thoracoscopic bullectomy. Group A (146 patients) was treated with an absorbable polyglycolic acid (PGA) sheet plus fibrin glue and oxidised regenerated cellulose (ORC). Group B (227 patients) was treated with ORC alone. RESULTS: There was no significant difference in preoperative characteristics of the patients. The postoperative recurrence rate of pneumothorax was 3.4% (5/146) in Group A and 17.2% (39/227) in Group B, respectively. Among 23 patients (Group A, n=3 and Group B, n=20) who received reoperation for recurrent pneumothorax, the site of recurrence was around the stapler line of the first operation in 1 of 5 (20%) patients in Group A and 28 of 39 (71.8%) patients in Group B. The 1-year recurrence-free rate was 97.4% (median follow-up period, 73 days (range, 2-3952 days)) in Group A and 80.9% (median follow-up period, 71 days (range 2-2648 days)) in Group B. CONCLUSIONS: Coverage with a PGA sheet may prevent the postoperative recurrence of PSP. A large-scale prospective randomised study should be conducted to clarify the most effective treatment for PSP.

A single-center analysis of 71 patients with thymic carcinoma: the chronological changes in the surgical procedure and prognosis.

Background: Effective treatments for thymic carcinoma (TC) have not been established due to its rarity and the prognosis has not yet been improved. In the present study, data of patients who underwent treatment for TC at our single institution were retrospectively reviewed to investigate the chronological changes in the clinical characteristics, surgical procedure, and prognosis. Methods: A total of 71 patients were included in this study. To investigate the chronological changes, the patients were divided into two groups at January 2009, when minimally invasive surgery (MIS) for thymic epithelial tumors (TETs) was introduced. Results: Among the 71 TC patients, 24 patients underwent surgery through December 2008 (earlier period), and 21 underwent surgery from January 2009 (later period). The patients in the later group were more likely to be diagnosed by chest computed tomography (CT) scan without subjective symptom. The rates of MIS and complete resection were significantly higher and the number of the patients at the early stage were significantly greater in the later group. The 5-year overall survival (OS) rate of the patients who underwent surgery at earlier and later groups were 58.7% and 92.8% respectively (P<0.01). Conclusions: The prognosis of TC has improved over time, thanks to early detection by CT screening and complete surgical resection.

Examination on the necessity of pericardial fat tissue resection in extended thymectomy for myasthenia gravis.

BACKGROUND: Extended thymectomy with pericardial fat tissue resection has been a mainstay in the treatment for myasthenia gravies (MG), but few studies have examined the necessity of the pericardial fat tissue resection in extended thymectomy. METHODS: We pathologically examined the distribution of germinal centers in the resected thymus including the thymus-surrounding fat tissue. Patients who underwent extended thymectomy using subxiphoid thoracoscopy for generalized MG or thymoma with anti-acetylcholine receptor antibody (anti-AchR Ab) positivity from March 2015 to January 2021 were included in this study. RESULTS: A total of 20 patients underwent extended thymectomy (generalized nonthymomatous MG, n=5; generalized MG with thymoma, n=6; thymoma with anti-AchR Ab positivity, n=9). The resected specimens were divided to 6 parts and were pathologically examined to investigate the distribution of the geminal centers in all lesions. The number and distribution of germinal centers in the thymus varied depending on the patient, and no germinal centers were identified in the right or left pericardial fat tissues. CONCLUSIONS: It is necessary to resect the pericardial fat tissue in patients whose preoperative images show the presence of pericardial fat tissue hyperplasia or ectopic thymoma. However, extensive pericardial fat tissue resection might not be necessary for all MG patients who undergo extended thymectomy with opening of the bilateral pleural by video-assisted or robot-assisted thoracoscopic surgery (RATS) via a subxiphoid approach.

Type A thymoma with simultaneous solitary intrapulmonary metastasis: A case report.

A 79-year-old woman was referred to our facility because of an abnormal chest shadow. Chest computed tomography (CT) showed a solitary right middle lung nodule with a maximum diameter of 3 mm and anterior mediastinal nodule with a maximum diameter of 21 mm. The lung nodule was suspected of being a primary lung cancer rather than a metastatic tumor because there were no primary malignant tumors, apart from an anterior mediastinal tumor visible on diagnostic imaging, including F18 fluorodeoxyglucose-positron emission tomography, and a solitary lung nodule. Partial lung resection by video-assisted thoracoscopic surgery (VATS) was performed, and the intraoperative frozen section of the tumor tissue resulted in a diagnosis of carcinoid tumor. As a result, right middle lobectomy by VATS was performed. The final histological diagnosis of the permanent specimen was intrapulmonary type A thymoma. VATS thymectomy was performed three months later. The histological diagnosis was type A thymoma with intrapulmonary metastasis (Masaoka stage IVb). Additional therapy was not performed because complete resection was achieved. Follow-up CT was performed once every six months after the operation. The patient has been followed up for one year without any further recurrence.

The usefulness of fluorodeoxyglucose-positron emission tomography as a preoperative diagnostic tool for thymic epithelial tumors.

BACKGROUND: To investigate the usefulness of 18F-fluorodeoxy glucose-positron emission tomography (18F-FDG PET) for the preoperative imaging diagnosis of malignant grade in thymic epithelial tumors (TETs) and the correlation between the maximum standardized uptake value (SUVmax) and tumor size in TETs. METHODS: We retrospectively investigated 51 patients with TETs performed 18F-FDG PET. The SUVmax was compared between thymic carcinomas and thymomas. We also evaluated the difference in the SUVmax limited to small TETs. In addition, the correlation between the SUVmax and the tumor size was evaluated. RESULTS: The mean SUVmax of thymic carcinomas (n=12) and thymomas (n=39) was 5.71±2.6 and 3.08±1.4, respectively. The SUVmax of thymic carcinomas was significantly higher than that of thymomas (P<0.001). The mean SUVmax of these small thymic carcinomas (n=3) and thymomas (n=13) was 2.97±0.24 and 1.79±0.47, respectively. The SUVmax of the small thymic carcinomas was significantly higher than that of the thymomas (P=0.001). We found a positive correlation between the SUVmax and the maximum tumor size of TETs (correlation coefficient: 0.632, P<0.001). CONCLUSIONS: 18F-FDG PET might be useful for evaluating the preoperative malignancy of TETs. Of note, the maximum tumor size should be considered when performing assessments by 18F-FDG PET.

Pericardial immunoglobulin G4-related inflammatory pseudotumor after right upper lobectomy for lung cancer.

A 75-year-old woman underwent thoracoscopic right upper lobectomy for lung cancer. A histopathological examination showed adenocarcinoma, pT1aN0M0 stage IA1. At six months after surgery, chest computed tomography (CT) revealed pericardial nodules that had not been detected before pulmonary resection. Postoperative CT performed two months later revealed that the nodules were growing and F18 fluorodeoxyglucose-positron emission tomography showed a maximum standardized uptake of 9.87. Blood tests revealed no elevated tumor markers, with the exception of a mildly elevated interleukin-2. Based on the above results, thoracoscopic biopsy was performed due to the suspected recurrence of lung cancer or malignant lymphoma. The histopathological examination of the nodule revealed immunoglobulin G4 (IgG4)-related inflammatory pseudotumor. The serum IgG4 levels were elevated (358 mg/dL, normal: 4.5-117.0 mg/dL). No additional treatment was required because all nodules were observed to have disappeared naturally on a follow-up CT scan performed two months after the surgical biopsy. The patient has been followed-up for two years without recurrence. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: We report a case of pericardial immunoglobulin G4-related inflammatory pseudotumor that appeared after right upper lobectomy for lung cancer, and which naturally disappeared without any treatment. WHAT THIS STUDY ADDS: There was an immunoglobulin G4-related inflammatory pseudotumor which appeared as multiple nodules in the pericardial space, and this should be kept in mind when considering the differential diagnosis of intrapericardial nodules.

Long-term survivor of pulmonary combined large cell neuroendocrine carcinoma treated with nivolumab.

Several authors have previously reported that patients with pulmonary combined large cell neuroendocrine cancer ( LCNEC) have a poor prognosis and there is no consensus on the treatment strategy for combined LCNEC as well as LCNEC. Here, we report the case of a long-term survivor with pulmonary combined LCNEC. The patient was a 60-year-old man who underwent thoracoscopic right lower lobectomy. The final histopathology and staging of the tumor showed LCNEC combined with squamous cell carcinoma and T2aN0M0 stage IB. Multimodality treatments including chemotherapy, radiotherapy and surgery for several recurrences were performed after the pulmonary surgery. After immune checkpoint inhibitor (ICI) therapy with nivolumab, all the metastatic lesions shrunk and a partial response was maintained at five years after the first surgery. In our case, ICI after multimodality therapy combining cytotoxic anticancer drugs and radiotherapy was effective in LCNEC with metachronous multiple metastases. KEY POINTS: SIGNIFICANT FINDINGS OF THE STUDY: Immune checkpoint inhibitor after multimodality therapy combining cytotoxic anticancer drugs and radiotherapy was effective in LCNEC with metachronous multiple metastases. The patient survived over five-years after the first surgery. WHAT THIS STUDY ADDS: Immune checkpoint inhibitor may be effective in some LCNEC patients.

Mixed-type primary germ cell tumor of the mediastinum in a young adult male with a sudden life threatening condition: A case report.

Primary germ cell tumors of the mediastinum are rare neoplasms. Above all, choriocarcinomas are highly aggressive with early haematogenous dissemination. Here, we report an extremely rare case of mixed-type primary germ cell tumor of the mediastinum which occurred in a 26-year-old man with multiple metastases of the lung caused by choriocarcinoma components, with diffuse pulmonary hemorrhaging. The patient developed a sudden life threatening condition a few days after a needle biopsy. KEY POINTS: Significant findings of the study: This was an extremely rare case of mixed-type germ cell tumor in a young adult male who developed a sudden life threatening condition due to choriocarcinoma components just a few days after a needle biopsy. What this study adds: Serious conditions may occur in patients with germ cell tumor containing choriocarcinoma components. At present, there is no other way to treat such patients than to promptly recognize complications and perform urgent multimodal intervention.

Thymic inflammatory pseudotumor with multilocular thymic cyst caused by immunoglobulin G4-related disease.

A 44-year-old man was referred to our hospital after an anterior mediastinal tumor was noted on computed tomography during follow-up observation after left testicular seminoma resection. Chest computed tomography revealed an enhanced mass measuring 33 x 16 x 15 mm at the anterior mediastinum. Chest magnetic resonance imaging revealed high signal intensity on T2-weighted imaging, and F18 fluorodeoxyglucose-positron emission tomography showed a maximum standardized uptake of 12.45. Laboratory tests revealed no elevated tumor markers, except for mildly elevated interleukin-2. Based on these results, complete resection was performed under suspicion of a malignant tumor, mediastinal metastasis of seminoma, or malignant lymphoma. An extended thymectomy with partial merger pericardial resection was performed using a subxiphoid approach. Small nodules and multiple thymic cysts were observed the thymus in addition to the main mass. Microscopic examination of the tumor revealed fibrosis, lymphocyte infiltration with lymphoid follicular hyperplasia, and hyperplasia of the thymus. Numerous immunoglobulin G4 (IgG4)-positive plasma cells were found on immunohistochemical staining. The ratio of IgG4 to total IgG was approximately 60%. We ultimately diagnosed the patient with a thymic inflammatory pseudotumor with multilocular cyst caused by IgG4-related disease.

Talc pleurodesis for secondary pneumothorax in elderly patients with persistent air leak.

BACKGROUND: We herein report the usefulness of two types of talc pleurodesis for secondary pneumothorax of elderly patients with persistent air leak who have severe pulmonary emphysema. METHODS: We assessed 17 elderly patients with persistent air leak who received talc pleurodesis for secondary pneumothorax from April 2013 to March 2017. Thoracoscopic talc poudrage (TTP) (n=11) was performed in patients whose general condition was thought to sufficiently stable to tolerate for general anesthesia. Talc slurry pleurodesis (TSP) (n=6) via a chest tube was performed in patients whose general condition was thought to be insufficiently stable to tolerate general anesthesia. RESULTS: The median drainage period after pleurodesis was 6 days in patients who received TTP and 12 days in patients who received TSP. Complications associated with talc pleurodesis included atrial fibrillation (n=1) in the thoracoscopic poudrage group, while the slurry pleurodesis group showed chest pain (n=2), asthmatic attack (n=1), and pneumonia (n=1). All patients who received thoracoscopic poudrage were able to leave the hospital after removal of the chest tube. Five of the six patients who received slurry pleurodesis were able to leave the hospital, but one of them died of acute exacerbation of interstitial pneumonia (IP) on the 45th day after pleurodesis. The success rate was 94% (16/17). There were no cases of recurrence during the observation period. CONCLUSIONS: TTP was deemed likely to be safe and effective for patients able to tolerate general anesthesia. In patients with IP, especially those treated with steroids, the indication of talc pleurodesis should be cautiously considered.

Hemothorax during miniaturized endoscopic combined intrarenal surgery under ureteroscope-assisted ultrasound-guided access.

INTRODUCTION: Hemothorax is a rare but life-threatening complication following mini-endoscopic combined intrarenal surgery. Herein, we describe a patient with left staghorn kidney stone who presented with hemothorax following mini-endoscopic combined intrarenal surgery under ureteroscope-assisted ultrasound-guided access. CASE PRESENTATION: A 47-year-old woman with left staghorn kidney stone underwent mini-endoscopic combined intrarenal surgery, after which she developed shortness of breath. Chest radiography and computed tomography confirmed left hemothorax. Conservative management and left intercostal chest drainage were performed without improvement. Subsequently, video-assisted thoracoscopic debridement was performed. CONCLUSION: Hemothorax is a severe complication of mini-endoscopic combined intrarenal surgery, which, regardless of accurate access through an ideal renal calyx under ureteroscope-assisted ultrasound-guided access, may lead to pleural injury. Refinement of the surgical technique and management after percutaneous nephrolithotomy is the key to avoiding life-threatening situations.