The Whitaker test: a predictive tool for evaluating the surgical efficacy of upper urinary tract reconstruction in patients carrying a nephrostomy tube after surgery.

PURPOSE: To explore the role of the Whitaker test in evaluating the postoperative outcome of upper urinary tract reconstruction surgery in patients carrying a nephrostomy tube after surgery. PATIENTS AND METHODS: This was a prospective observational study performed in 42 patients with nephrostomy tube undergoing the Whitaker test after upper urinary tract reconstruction surgery between January 2020 and December 2021. Data on clinical information, the Whitaker test and surgical procedure were collected prospectively, and the long-term follow-up results were analysed retrospectively. RESULTS: The 46 ureters of 42 patients (right 16, left 22, bilateral 4) underwent six common upper urinary tract surgical reconstruction procedures and one combined procedure, including pyeloplasty, ureteroureterostomy, lingual mucosal onlay graft, appendiceal onlay flap, ureteral reimplantation, Boari flap, and ipsilateral lingual mucosal onlay graft combined ureteral reimplantation. All patients underwent the Whitaker test successfully without any discomfort after examination. The postoperative Whitaker test showed 43 kidneys without obstruction and 3 kidneys with obstruction. At a median follow-up of 18 months (range 13-31), the follow-up results showed that the overall success rate of the surgery was 100% (46/46). Concerning the concordance Whitaker test and follow-up results, the observed proportion of agreement was 93.5% (43/46). CONCLUSION: The Whitaker test can achieve similar consistency with the long-term follow-up results after upper urinary tract reconstruction surgery and can be used as a tool to evaluate the surgical efficacy of upper urinary tract reconstruction surgery, which can provide a prognostic efficacy evaluation for patients carrying a nephrostomy tube after surgery.

Treating Multifocal Ureteral Strictures with Combined Techniques: 14 Cases of Initial Experience.

Purpose: To evaluate the safety and feasibility of lingual mucosal graft ureteroplasty (LMGU) combined with ureteral reimplantation (UR) for repairing managing multifocal ureteral strictures (MUS). Methods: Between December 2020 and December 2022, 14 patients underwent LMGU combined with UR. Their perioperative data were collected retrospectively and analyzed. For the proximal diseased ureter, the narrow segment was incised longitudinally to open the ventral wall of ureter, and a lingual mucosal graft was placed as an onlay graft. Meanwhile, UR was applied to treat distal ureteral strictures. Results: Of 14 patients, three (21.4%) had previously undergone a failed ureteral reconstruction. The mean (standard deviation [SD]) proximal stricture length was 4.0 cm (1.56), and distal ureteral stricture length was 4.3 cm (0.94). The mean (SD) operative time was 236 minutes (57), the estimated blood loss was 78 mL (41.5), and the length of postoperative stay was 6 days. One (7%) patient underwent double LMGU to treat proximal 2 segments of ureteral stricture. No open conversions and intraoperative complications occurred. With a mean follow-up of 15 months (range 6-29), the recurrence-free rate was 14/14 (100%). Conclusions: LMGU combined with UR is a feasible and effective technique for managing MUS and can be an alternative to ileal ureteral replacement or renal autotransplantation in some selected patients with MUS.

Robotic-assisted appendiceal onlay flap ureteroplasty combined with ureteral reimplantation for multifocal ureteral strictures: Case report and technical description.

BACKGROUND: To describe the surgical technique of robotic-assisted appendiceal onlay flap ureteroplasty combined with ureteral reimplantation to repair unilateral multifocal ureteral strictures in one stage and report 9-month follow-up outcomes. METHOD: A longitudinal ventral incision of proximal ureter strictures No. 1 and 2 was performed, and the appendix was detubularised along its antimesenteric border. Then, the appendiceal onlay flap was anastomosed with the spatulated ureter in an onlay fashion. To manage the distal ureteral stricture No. 3, ureteral reimplantation was performed in a tension-free manner. RESULTS: Voiding cystourethrography and antegrade urography showed urine regurgitation into the ureter without dilation and no obstruction of the reconstructed ureteral segment 7 weeks after surgery. No postoperative complications occurred during the 9-month follow-up. CONCLUSIONS: Robotic-assisted appendiceal onlay flap ureteroplasty combined with ureteral reimplantation appears to be a safe and effective surgical method for repairing the unilateral multifocal ureteral strictures.

Robotic-assisted double lingual mucosal graft ureteroplasty for multifocal ureteral strictures: Case report and technical description.

BACKGROUND: Ureteroplasty with a single onlay graft for proximal ureter stricture has been widely used in the clinic. However, robotic ureteroplasty with a double lingual mucosal graft (RU-DLMG) has not been reported. METHODS: The intraoperative measured ureteral stricture lengths of patient 1 were 1.8, 2.5, and 4.6 cm, and those of patient 2 were 2.5 and 3.5 cm. We performed a RU-DLMG in which the diseased ureter was incised longitudinally from the ventral side and repaired with a double lingual mucosal graft to widen the ureteral lumen. Because of the presence of a distal ureter stricture, RU-DLMG combined with ureteral reimplantation was performed in patient 1. RESULTS: Antegrade urography showed no obstruction of the reconstructed ureteral segment after removing the ureteral stent. The patients had no complaints about the donor site and flank pain during the 12-month follow-up. CONCLUSIONS: RU-DLMG appears to be a suitable option for multifocal ureteral strictures.

Oral mucosal graft ureteroplasty versus ileal ureteric replacement: a meta-analysis.

OBJECTIVES: To describe outcomes of oral mucosal graft ureteroplasty (OMGU) and ileal ureter replacement (IUR) and determine the relative merits of both procedures. METHODS: Databases (including PubMed, Embase and Cochrane) were interrogated for eligible trials that assessed outcomes of OMGU or IUR from 2000 to 30 July 2022. The variables analysed were reconstruction success rates, stricture length, hospital stays, perioperative complications and long-term complications. RESULTS: A total of 23 single-arm studies were included. The pooled reconstruction success rates for OMGU and IUR were 94.9% (95% confidence interval [CI] 91.0%-97.7%) and 85.8% (95% CI 81.0%-90.0%), respectively. Stricture length of patients in the OMGU and IUR groups were 3.73 (95% CI 3.17-4.28) and 11.55 (95% CI 9.82-13.29) cm, respectively. The maximal stricture length repaired by OMGU was 8 cm. The hospital stays were 5.85 (95% CI 3.88-7.82) and 11.55 (95% CI 6.93-16.17) days in the OMGU and IUR groups, respectively. The incidences of low-grade postoperative complications were 13.6% (95% CI 6.9%-20.3%) and 27.3% (95% CI 19.5%-35.1%), high-grade postoperative complications were 4.6% (95% CI 1.8I-8.5%) and 13.0% (95% CI 9.4%-17.1%), and long-term complications (occurred at > 3months) were 9.0% (95% CI 1.7%-20.0%) and 35.4% (95% CI 25.8%-45.6%) in the OMGU and IUR groups, respectively. CONCLUSION: An OMGU is an effective, minimally invasive, and safe alternative to IUR for the management of long ureteric strictures. OMGU was the preferred treatment for long ureteric strictures, especially obstructed ureter segments of ≤8 cm.

Lingual Mucosal Graft Ureteroplasty for Long Proximal Ureteral Stricture: 6 Years of Experience with 41 Cases.

BACKGROUND: Management of a long proximal ureteral stricture is challenging. Lingual mucosal graft ureteroplasty (LMGU) is a novel minimally invasive technique for ureteral reconstruction that avoids the morbidity of bowel interposition or autotransplantation. OBJECTIVE: To evaluate the long-term effectiveness of LMGU for managing long, complex proximal ureteral strictures in a multi-institutional cohort of patients. DESIGN, SETTING, AND PARTICIPANTS: This retrospective study involved data for 41 patients treated with LMGU at three centers between June 2015 and January 2021. SURGICAL PROCEDURE: LMGU was performed using either an onlay ureteroplasty in which the diseased ureter was incised ventrally and repaired with a lingual mucosal graft (LMG) to widen the ureteral lumen, or an augmented anastomotic technique in which the obliterated segment of the ureter was excised and reanastomosed primarily on dorsal side, and an LMG was placed on the ventral side. MEASUREMENTS: Pre-, intra-, and postoperative variables and outcomes were assessed. A descriptive statistical analysis was performed. RESULTS AND LIMITATIONS: Of 41patients, 40 were operated with laparoscopic procedures and one with a robot. Twenty-four (59%) patients underwent an onlay ureteroplasty, and 17 (41%) underwent an augmented anastomotic ureteroplasty. The reconstructed ureter was wrapped with omentum in 90% of cases. The median (range) stricture length was 4.8 cm (2.0-8.0), operative time was 166 min (98-306), and estimated blood loss was 65 ml (15-220). No open conversions and intraoperative complications occurred. At a median follow-up of 35 mo (range 13-80), the overall success rate was 97.6% (40/41). CONCLUSIONS: LMGU is a safe, feasible, and effective long-term technique for managing long, complex proximal ureteral strictures. PATIENT SUMMARY: We reported a novel technique for long proximal complex ureteral strictures using an onlay lingual mucosal graft (LMG). Our 6-yr outcomes demonstrate that onlay LMG ureteroplasty is a safe, feasible, and effective long-term procedure for ureteral reconstruction.

Restoration of the penile sensory pathway through end-to-side dorsal root neurorrhaphy in rats.

Objective: Spinal cord injury often leads to the loss of penile sensation, and severely affects the individual's sexual function. The present study aimed to restore the penile sensory pathway through end-to-side dorsal root (DR) transfer neurorrhaphy in rats, and preliminarily verified the feasibility of the operation.Design: 40 male adult Sprague-Dawley rats were divided into three groups. In the model (n = 20) and resection (n = 10) groups, the right L6 DR, S1 DR, and the contralateral branch of the dorsal nerve of the penis (DNP) were transected. The distal stump of L6 DR in the model group was then anastomosed to the intact L4 DR. The sham group (n = 10) was not subjected to neural damage. Four months later, retrograde and transganglionic neural labeling, morphological examination, immunofluorescence (IF), and ultrastructural observation were carried out to test the reconstruction of the afferent pathway. Reflective erection (RE) was assessed by detecting the intracavernous pressure elicited by DNP stimulation.Results: The neural labeling tests indicated the integrity of the entire rebuilt penile afferent pathway. The morphological studies, IF, and ultrastructural observation showed that the regeneration of L6 axons in the model group was significantly better than that in the resection group; however, it had not reached the level of the sham group. The sham group rats exhibited typical RE following DNP stimulation, while the model and resection groups produced negative results.Conclusion: Our studies demonstrated the feasibility of end-to-side DR transfer neurorrhaphy for restoring the penile sensory pathway in rats.

Should surgical drainage after lateral transperitoneal laparoscopic adrenalectomy be routine?-A retrospective comparative study.

BACKGROUND: Whether to use surgical drains after abdominal surgery or not has received much attention since a hundred years ago. Nowadays, lateral transperitoneal laparoscopic adrenalectomy (LTLA) is a widely used technique to treat adrenal tumors worldwide. However, the placement of drains after LTLA remains controversial. METHODS: Data of 150 patients, who underwent LTLA between October 2014 and September 2020 by the same lead surgeon, were collected, including demographic, pathology, preoperative, operative variables and postoperative complications. The patients were divided into two groups, with and without drainage. The postoperative recovery of the two groups was compared. RESULTS: Among 150 patients (65 men and 85 women, median age 48 years, median BMI 23.53), 89 patients had no drainage and 61 patients had drainage after surgery. Variables of the two groups were analyzed. Placement of drains correlated with long operative time (P<0.01). Patients with drain had longer hospital stays (P<0.001) and a higher incidence of postoperative complications (P=0.022). Other factors, including tumor size (P=0.61), tumor location (P=0.387), ASA score (P=0.687), pathology (P=0.55), VAS pain score (P=0.41), intraoperative blood loss (P=0.11), were not found to be significantly associated with drain placement. There was no conversion to open surgery in both groups. Moreover, no mortality was observed in either group. CONCLUSIONS: This study revealed that it is feasible and safe not to leave a drain in selective and uncomplicated patients and that surgical drainage should not be routine after LTLA.

Restoration of Penile Sensation Through Neurological Bypass in Rats.

OBJECTIVE: To explore the feasibility of the penile afferent pathway by the cutaneous branch of the genitofemoral nerve to the dorsal nerve of penile transfer in rats. METHODS: A total of 54 male rats were randomly divided into model group (n = 18), resection group (n = 18), and sham group (n = 18). In the model group, the distal stump of bilateral DNP was anastomosed to the proximal stump of the bilateral CGN through end-to-end neurorrhaphy. In the resection group, bilateral DNP was severed and ligated, and no end-to-end anastomosis was performed. Only a surgical incision was made in the sham group, and no nerve injury was caused. After the operation, the feasibility of reconstructing the penile afferent pathway was explored by fluorescent-gold retrograde neural labeling. The intracavernous pressure assessment was then carried out. The morphological examination, histological staining of nerves, and ultrastructural observation were performed accordingly. RESULTS: Fluorescent-gold labeled L1 and L2 neurons in the model group were positive. The mean ICP in the model group was (12.02 ± 2.03 mmHg), which is higher than the mean value in the resection group (0 mmHg, P < .05) but lower than that in the sham group (36.95 ± 5.33 mmHg; P < .05). The morphological studies, HE, and ultrastructure observation revealed that the regeneration of DNP axons in the model group was significantly better than that in the resection group yet did not reach the level of the sham group. CONCLUSION: This experiment preliminarily proved the feasibility of restoration of the penile afferent pathway by CGN to DNP transfer in Rats.

Laparoscopic "reverse 7" ileal ureteral replacement for bilateral extensive ureteral strictures performed completely intracorporeally: the initial experience.

PURPOSE: To present our initial experience and evaluate the feasibility of the novel technique of completely intracorporeal laparoscopic "reverse 7" ileal ureteral replacement (IUR). MATERIALS AND METHODS: Between December 2018 and September 2019, two patients underwent completely intracorporeal laparoscopic "reverse 7" IUR, which were female patients with bilateral extensive ureteral strictures (BEUS) secondary to radical hysterectomy and pelvic lymph node dissection for cervical cancer and postoperative radiotherapy. Antegrade pyelography and retrograde pyelography showed BEUS preoperatively. RESULTS: The novel technique was performed successfully by the same surgeon without conversion to open surgery. The operating time of each patient was 420 min and 410 min, respectively. Meanwhile, the estimated blood loss of each patient was 120 ml and 100 ml, respectively. There were no major complications during the perioperative period. After ureteral stent was removed, antegrade pyelography postoperatively revealed excellent drainage with the resolution of hydronephrosis in both patients. After removing of ureteral stent and nephrostomy tube, no patients have a complaint about the donor site or the onset of flank pain. CONCLUSIONS: To our knowledge, we present the initial experience with completely intracorporeal laparoscopic "reverse 7" IUR. With initial follow-up outcomes, this novel minimally invasive technique appears to be feasible and efficacious in treating BEUS in carefully selected patients.

Efficacy of Eutectic Mixture of Local Anesthetics on Pain Control During Extracorporeal Shock Wave Lithotripsy: A Systematic Review and Meta-Analysis.

BACKGROUND The efficacy of a eutectic mixture of local anesthetics (EMLA) for pain control in extracorporeal shock wave lithotripsy is unclear. The aim of this study was to assess the effect of EMLA cream on pain control during extracorporeal shock wave lithotripsy. MATERIAL AND METHODS We searched Medline, EMBASE, and the Cochrane Central Register of Controlled Trials to identify relevant randomized controlled trials that compared the pain control efficacies of EMLA vs. placebo. Study eligibility criteria, participants, and interventions: Randomized controlled trials that compared the effect of EMLA with placebo cream for patients underwent extracorporeal shock wave lithotripsy. Study appraisal and synthesis methods: Two review authors extracted data independently using a designed data extraction form and risk of bias by Cochrane Collaboration's tool. RESULTS Nine studies, including 10 randomized controlled trials with 1167 patients, were eligible. The EMLA group experienced less pain (mean difference, -0.47; 95% confidence interval, -0.78 to -0.16; p=0.003) and shorter duration of lithotripsy (mean difference, -1.70, 95% confidence interval: -2.31 to -1.10, p<0.0001) than the placebo group. There were no significant differences in the number of patients who needed extra intravenous medication (p=0.610), number of patients with insufficient extracorporeal shock wave lithotripsy pain control (p=0.530), and number of patients with opioid adverse effects (p=0.320). Limitations: Long interval between the studies, different kinds of lithotripters. CONCLUSIONS EMLA can reduce pain during the ESWL procedure.

The immune infiltration in clear cell Renal Cell Carcinoma and their clinical implications: A study based on TCGA and GEO databases.

The tumor immune microenvironment in clear cell Renal Cell Carcinoma (ccRCC) still remains poorly understood. Previous methods to study the tumor immune microenvironment have a limitation when accounting for the functionally distinct cell types. In this study, we investigated the differently infiltrated immune cells and their clinical significance in ccRCC for the purpose of shedding some important light on the complex immune microenvironment in ccRCC. The devolution algorithm (CIBERSORT) was applied to infer the proportion of 22 immune infiltrating cells based on gene expression profiles of ccRCC bulk tissue, which were downloaded from TCGA and GEO databases. As a result, we observed considerable differences in immune cells percentage between ccRCC tumor tissue and paired normal tissue; meanwhile, we uncovered their internal correlations and associations with Fuhrman grade. Moreover, dendritic cells resting, dendritic cells activated, mast cells resting, mast cells activated and eosinophils were associated with favorable prognosis, whereas B cells memory, T cells follicular helper and T cells regulatory (Tregs) were correlated with poorer outcome.

TFEB Mediates Immune Evasion and Resistance to mTOR Inhibition of Renal Cell Carcinoma via Induction of PD-L1.

PURPOSE: Despite the FDA approval of mTOR inhibitors (mTORi) for the treatment of renal cell carcinoma (RCC), the benefits are relatively modest and the few responders usually develop resistance. We investigated whether the resistance to mTORi is due to upregulation of PD-L1 and the underlying molecular mechanism. EXPERIMENTAL DESIGN: The effects of transcription factor EB (TFEB) on RCC proliferation, apoptosis, and migration were evaluated. Correlation of TFEB with PD-L1 expression, as well as effects of mTOR inhibition on TFEB and PD-L1 expression, was assessed in human primary clear cell RCCs. The regulation of TFEB on PD-L1 was assessed by chromatin immunoprecipitation and luciferase reporter assay. The therapeutic efficacies of mTORi plus PD-L1 blockade were evaluated in a mouse model. The function of tumor-infiltrating CD8+ T cells was analyzed by flow cytometry. RESULTS: TFEB did not affect tumor cell proliferation, apoptosis, and migration. We found a positive correlation between TFEB and PD-L1 expression in RCC tumor tissues, primary tumor cells, and RCC cells. TFEB bound to PD-L1 promoter in RCCs and inhibition of mTOR led to enhanced TFEB nuclear translocation and PD-L1 expression. Simultaneous inhibition of mTOR and blockade of PD-L1 enhanced CD8+ cytolytic function and tumor suppression in a xenografted mouse model of RCC. CONCLUSIONS: These data revealed that TFEB mediates resistance to mTOR inhibition via induction of PD-L1 in human primary RCC tumors, RCC cells, and murine xenograft model. Our data provide a strong rationale to target mTOR and PD-L1 jointly as a novel immunotherapeutic approach for RCC treatment.