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In this real-world study, we aimed to elucidate the predictive value of tumour-associated stroma for clinical prognostic and therapeutic response in upper tract urothelial carcinoma (UTUC) by reviewing the clinicopathologic characteristics of 1015 UTUC patients through a nationwide multicenter analysis.The tumour-stroma ratio (TSR) was assessed based on tissue sections stained for hematoxylin and eosin (HE), and patients were further stratified into stroma-high (50% stroma) and stroma-low group (≤50% stroma). Kaplan-Meier curve and Cox regression hazard analysis were conducted to assess the survival outcomes of UTUC patients. Bioinformatics analysis and immunostaining analysis were applied to portray the tumour microenvironment (TME).Stroma-high UTUC was significantly associated with poorer survival outcomes and inferior chemotherapeutic responsiveness. Our established nomogram achieved a high prognostic accuracy in predicting overall survival and cancer-specific survival in both of the discovery cohort (area under the curve [AUC] 0.663 and 0.712) and the validation cohort (AUC 0.741 and 0.747). Moreover, stroma-high UTUC was correlated with immunoevasive TME accompanied by increased cancer-associated fibroblasts, tumour-associated macrophages and, conspicuously a cluster of highly exhausted CD8Our results showed stroma-high UTUC was associated with an inferior prognosis and an immunoevasive TME with exhausted CD8

Background To describe our initial experience with robotic ureteral reimplantation for the management of ureterovaginal fistulas. Methods Between January 2018 and January 2020, four patients received robotic ureteral reimplantation for ureterovaginal fistulas. All patients were diagnosed based on anterograde urography and computed tomography urography (CTU). Follow-up was performed with magnetic resonance urography and renal ultrasound as well as the clinical assessment of symptoms. Results The mean age of all patients was 50.3 (range, 37-65) years. The cause of the ureterovaginal fistula in four patients was due to a previous hysterectomy. The mean time from fistula diagnosis to robotic repair surgery was 14.5 (range, 3-36) months. All robotic procedures were successfully performed without intraoperative complications or open conversion. The mean operative time was 137 (range, 116-171) minutes, and the mean estimated blood loss was 25 (range, 10-50) mL. No postoperative complications that were high grade (grade III and IV) occurred within one month of surgery. Patients had the double-J (D-J) stents removed 2 months after surgery and the nephrostomy tubes removed 3 months after the operation. There was a 100% success rate without serious complications, such as the leakage of urine and side progressive hydronephrosis, during the 6 to 24 months of follow-up. Conclusions Our initial results and experience showed that robotic ureteral reimplantation for the management of ureterovaginal fistula is safe and feasible.

Chylothorax is a serious complication after esophagectomy and an important reason for reoperation and prolonged hospital stay. A clear localization of thoracic ducts (TDs) and the potential leakage site is an ideal strategy to prevent postoperative chylothorax. In order to explore the feasibility and safety of near-infrared fluorescence imaging (NIR-FI) with indocyanine green (ICG) to identify TDs and potential chyle leakage during video-assisted thoracoscopic esophagectomy, a prospective clinical trial was conducted. We recruited 41 patients who underwent thoraco-laparoscopic minimally invasive esophagectomy for esophageal cancer in this prospective, single-arm clinical study between December 2020 and December 2021. The primary endpoint was the performance of NIR-FI in identifying TDs and chyle leakage. The ICG was injected subcutaneously into the right inguinal region 30 minutes before the thoracic operation, and it becomes fluorescent when excited by the light with a special wavelength in the NIR system. According to the intraoperative demands, surgeons can observe the position of the TDs under the real-time guidance of NIR-FI. In 38 of 41 patients (92.7%) using NIR-FI, TDs were clearly visible in high contrast. The mean signal-to-background ratio (SBR) of all fluorescent TDs was 3.05 ± 1.56. Fluorescence imaging of TDs could be detected 0.5 hours after ICG injection and last up to 3 hours with an acceptable SBR value. The optimal observation time window is from about 1 to 2 hours after ICG injection. Under the guidance of real-time NIR-FI, three patients were found to have chylous leakage and the selective TD ligation were performed intraoperatively. No patient had postoperative chylothorax. NIR-FI with ICG can provide highly sensitive and real-time assessment of TDs, as well as determine the source of chyle leakage, to prevent TD injury and direct selective TD ligation. It’s an effective navigation tool to minimize the incidence of chylothorax after minimally invasive esophagectomy.

To compare the perioperative and oncologic outcomes between minimally invasive pelvic organ-preserving radical cystectomy (MIPOPRC) and open pelvic organ-preserving radical cystectomy (open POPRC) among female patients with bladder cancer (BCa).We identified female patients who underwent POPRC for BCa at three centers between January 2006 and April 2018. Female patients who underwent open POPRC were matched with those who underwent MIPOPRC using 1:1 propensity score (PS) matching. The patient demographics and perioperative and oncologic outcomes were evaluated for the comparison between MIPOPRC and open POPRC.Among the 158 patients enrolled, 83 patients underwent MIPOPRC, and 75 underwent open POPRC. A total of 60 MIPOPRC and 60 open POPRC patients were matched successfully. The cancer-specific survival (CSS) and recurrence-free survival (RFS) did not differ significantly in the propensity score-weighted cohort (p = 0.297 and p = 0.600, respectively). Subgroup analysis by age and pathologic stage in the matched cohort revealed that CSS and RFS were with no differences among all subgroups. Moreover, multivariable Cox regression analyses showed that the surgical approach (MIPOPRC vs open POPRC) was not a predictor of CSS (p = 0.250).MIPOPRC was non-inferior to open POPRC in terms of oncologic outcomes among female patients. MIPOPRC could be technically feasible in selected female patients with BCa.

Summary Chylothorax is a serious complication after esophagectomy and there are unmet needs for new intraoperative navigation tools to reduce its incidence. The aim of this study is to explore the feasibility and effectiveness of near-infrared fluorescence imaging (NIR-FI) with indocyanine green (ICG) to identify thoracic ducts (TDs) and chyle leakage during video-assisted thoracoscopic esophagectomy. We recruited 41 patients who underwent thoraco-laparoscopic minimally invasive esophagectomy (MIE) for esophageal cancer in this prospective, open-label, single-arm clinical trial. ICG was injected into the right inguinal region before operations, after which TD anatomy and potential chyle leakage were checked under the near-infrared fluorescence intraoperatively. In 38 of 41 patients (92.7%) using NIR-FI, TDs were visible in high contrast. The mean signal-to-background ratio (SBR) value of all fluorescent TDs was 3.05 ± 1.56. Fluorescence imaging of TDs could be detected 0.5 hours after ICG injection and last up to 3 hours with an acceptable SBR value. The optimal observation time window is from about 1 to 2 hours after ICG injection. Under the guidance of real-time NIR-FI, three patients were found to have chylous leakage and the selective TD ligations were performed intraoperatively. No patient had postoperative chylothorax. NIR-FI with ICG can provide highly sensitive and real-time assessment of TDs as well as determine the source of chyle leakage, which might help reduce TD injury and direct selective TD ligation. It could be a promising navigation tool to reduce the incidence of chylothorax after minimally invasive esophagectomy.

The limited response rate of immunotherapy in upper tract urothelial carcinoma (UTUC) might be attributed to additional immunosuppressive mechanisms in vivo. As a promising immune checkpoint target, the expression and prognostic role of indoleamine 2,3-dioxygenase 1 (IDO1) in UTUC remains unknown. In this study, the expression and prognostic value of IDO1 was analyzed in 251 patients from 3 independent cohorts. The least absolute shrinkage and selection operator (LASSO) Cox regression model was used to construct an IDO1-based immune classifier and external validation was performed to further validate the classifier. RNA sequencing and immunofluorescence were used to explore the immune contexture of different risk groups stratified by classifier. We found that high IDO1 expression on tumor cells (TC) indicated a poorer overall survival and disease-free survival in all cohorts. Patients with high expression of IDO1 TC possessed increased infiltration of CD4

BackgroundTo present the experience with the surgical management of ureteral endometriosis (UE) in our single center.MethodsTo present the experience with the surgical management of ureteral endometriosis (UE) in our single center. A retrospective analysis of 40 patients with UE who presented with intraoperative surgical findings of endometriosis involving the ureter and pathology-proven UE was performed.ResultsForty patients (median age, 42.5 years) with histological evidence of UE were included. Six (15%) patients had a history of endometriosis. Twenty-one (52%) patients had urological symptoms, and 19 (48%) patients were asymptomatic. All patients had hydronephrosis. The mean glomerular filtration rate (GFR) of the ipsilateral kidney was significantly worse than that of the contralateral kidney (23.4 vs 54.9 ml/min;P ConclusionsAlthough UE is rare, we should remain vigilant for the disease among female patients with silent hydronephrosis. Typically, a multidisciplinary surgical team is necessary. For patients with severe UE, segmental ureteral resection with ureteroureterostomy (UU) or ureteroneocystostomy may be a preferred choice.

Open Anderson-Hynes dismembered pyeloplasty was the criterion standard for ureteropelvic junction obstruction. Laparoscopic pyeloplasty was comparable to open pyeloplasty in success rates while laparoscopic pyeloplasty offered the advantages of decreased morbidity, shorter hospital stay, and quicker recovery. While laparoscopic pyeloplasty was accompanied with the slow learning curve due to technically demanding and time-consuming intracorporal suturing, which has limited its widespread use. Robotic pyeloplasty and laparoscopic pyeloplasty were comparable regarding complication rate, success rate and operative time.

Background The aim of this study was to evaluate the effectiveness and safety of real-time surgical navigation by three-dimensional (3D) virtual reconstruction models in robot-assisted laparoscopic pyeloplasty (RALP). Methods Between November 2018 and January 2020, 38 patients with ureteropelvic junction obstruction (UPJO) who underwent RALP were retrospectively enrolled. The operations were assisted in real time by 3D models in 16 patients, while 22 patients underwent surgery without navigation. Based on whether patients had a prior intervention history, crossing vessels or congenital deformities, we further divided them into the "complicated UPJO" cohort and the "regular UPJO" cohort for subgroup analysis. The demographic characteristics, intraoperative parameters, perioperative data and follow-up data were recorded and compared between the groups. Results All of the procedures were successfully performed without open or laparoscopic conversion. The mean dissection time to the UPJ was shorter in the navigation group than in the non-navigation group, both in the whole cohort (15.3 vs. 24.8 min, P=0.011) and in the complicated cohort (15.4 vs. 27.5 min, P=0.004), while there was no significant difference in the regular cohort. The overall operative time and estimated blood loss in the navigation group tended to be less, although the difference was not statistically significant. No difference in anastomosis time, postoperative hospital stay or complications was noted between the two groups in either cohort. At a mean follow-up of 11.2 months, the overall success rate was 94.7% (36/38), and there was no significant difference between the two groups. Conclusions Real-time navigation by 3D virtual reconstruction models might be helpful to improve surgical efficiency and safety of RALP by facilitating the dissection around the UPJ, especially for cases of complicated UPJO. However, the prospective study with larger sample size is further needed to confirm the results.

Background To summarize our experience with the Boari flap-psoas hitch and compare the indications, perioperative data and outcomes between open and laparoscopic procedures. Methods This study retrospectively reviewed 35 patients with complex distal ureteral stricture between January 2015 and April 2019. All patients were treated with Boari flap-psoas hitch by either an open or a laparoscopic procedure. Selection criteria were based on the etiology, comorbidities, medical history, and patient preference. Results All surgeries were performed successfully. The median operation time was 201 min (range, 120 to 300 min), and the median estimated blood loss was 50 mL (range, 20 to 400 mL). The median postoperative hospitalization was 9 days (range, 3 to 46 days). Nineteen patients were treated by the open procedure, and 16 were treated by the transperitoneal laparoscopic procedure. The surgical indication of open surgery was broader than that for laparoscopic surgery. For patients experiencing iatrogenic injury and ureterovesical reimplantation failure, no significant differences in sex, laterality, operative time, ASA score or postoperative hospitalization stay were observed between the two groups. The median estimated blood loss was lower in the laparoscopic group than in the open group (P=0.047). Patients in the open group had more surgical complications than patients in the laparoscopic group (P=0.049). The postoperative follow-up showed the radiological resolution of hydronephrosis in 33 patients. Conclusions With the appropriate surgical considerations, Boari flap-psoas hitch is a valid method to bridge distal ureteral defects. For select patients, laparoscopic surgery had advantages being a minimal invasive surgery with less estimated blood loss and fewer surgical complications.

Background To present our experience with the "omental wrapping" technique in laparoscopic and robotic ureteroplasty using onlay flaps or grafts for the management of long proximal or middle ureteral strictures. Methods This is a retrospective review of 25 patients with long proximal or middle ureteral strictures who underwent laparoscopic and robotic onlay flaps or grafts ureteroplasty using an omental flap to reinforce an anastomosis site between August 2018 and November 2019. Perioperative and follow-up data were collected. Results Sixteen laparoscopic procedures and nine robotic procedures were performed successfully. Sixteen patients underwent ureteroplasty with lingual mucosal graft (LMG), and nine patients with appendiceal onlay flap (AOF). The median stricture length was 4 cm (range, 2-6 cm). The mean operative time (OT) was 220.5±50.6 min, the estimated blood loss (EBL) was 66.0±38.9 mL, and the length of hospital stay (LHS) was 8.0±3.6 days. In the LMG group, four patients had tongue numbing and one had an oral ulcer, which relieved itself gradually without intervention. Two patients in the LMG group and four patients in the AOF group experienced urinary tract infection, and all responded well to antibiotic treatment. There were no complications attributed to "omental wrapping". The mean follow-up was 16.3±4.8 months. According to the standards regarding improvement in clinical symptoms, relief of obstruction radiologically and a stable estimate glomerular filtration rate, our surgical success rate was 100%. Conclusions The "omental wrapping" technique in laparoscopic and robotic onlay flaps or grafts ureteroplasty for long proximal or middle ureteral strictures is an efficient, safe, reproducible and simple technique.

Background: Immunotherapy for upper tract urothelial carcinoma (UTUC) shows potential, but only a small subset of patients benefits from the treatment. This disadvantage can be attributed to additional immunosuppressive mechanisms in vivo. Indoleamine 2,3-dioxygenase 1 (IDO1) can be potentially used as an immune checkpoint target. We conducted this study to determine the prognostic role of IDO1 in UTUC and further construct an immune classifier, which can provide additional prognostic information and personalized treatment for UTUC. Methods: Two hundred and fifty-one tumor tissues of UTUC from three independent cohorts were analyzed. The expression of IDO1, programmed cell death protein 1-ligand 1 (PD-L1) and the infiltration of CD4+/CD8+/Foxp3+ T cells were evaluated using immunohistochemistry staining. Kaplan-Meier curves and Cox model were used for comparing the clinical outcomes. The Lasso Cox regression model was used to construct an IDO1-based immune classifier. Internal and external validation cohorts were included to validate the classifier. The immune contexture of different risk group stratified by the immune classifier were measured by RNA sequencing and immunofluorescence. Results: High IDO1 expression on tumor cells (TC) indicated a poorer overall survival and disease-free survival compared with low IDO1 expression in all cohorts. Patients with high expression of IDO1 TC possessed increased infiltration of Foxp3+ regulatory cells, CD8+ and CD4+ T cells. However, the distribution of IDO1 expression was irrelevant with that of PD-L1. An immune classifier based on intratumoral CD8+ lymphocytes, IDO1 TC and stromal PD-L1 expression status was developed, with its AUC values for OS at 5 years being 0.79 (95% CI 0.65-0.93) in the discovery cohort, 0.75 (95% CI 0.58-0.92) and 0.78 (95% CI 0.65-0.92) in the internal and external validation cohort, respectively. Moreover, the high-risk group stratified by our immune classifier was associated with immunosuppressive contexture, accompanied by enhanced CD8+ T cells exhaustion patterns. Conclusion: Our IDO1-based immune classifier can provide a superior accuracy for survival prediction and lead to individual stratification of UTUC immune subtypes. Funding: This study was supported by the National Natural Science Foundation of China (grant no. 81825016, 81902586); Guangdong Provincial Natural Science Foundation (grant no. 2021A1515011541); Guangdong Provincial Clinical Research Center for Urological Diseases (grant no. 2020B1111170006); Key Laboratory of Malignant Tumor Gene Regulation and Target Therapy of Guangdong Higher Education Institutes (grant no. KLB09001); Key Laboratory of Malignant Tumor Molecular Mechanism and Translational Medicine of Guangzhou Bureau of Science and Information Technology (grant no. 013-163); Key Laboratory of Tumor Immunoprevention Research of Yunnan Province (grant no. 2017DG004-04); The Health Science and Technology Talents Training and “Ten, Hundred and Thousand” Project of Kunming (grant no. 2018-sw-004); Yunnan Basic Research Program- Kunming Medical University Joint Project (grant no. 2018FE001-090). Declaration of Interest: None to declare. Ethical Approval: The study was approved by the ethics committee of Sun Yat-sen Memorial Hospital and Peking University First Hospital.

Objectives: The aim of the study was to present our modified flap pyeloplasty techniques for recurrent ureteropelvic junction obstruction (UPJO) with a long proximal ureteral stricture and compare outcomes of laparoscopic and robotic procedures. Materials and Methods: Between March 2018 and January 2020, 21 patients underwent modified laparoscopic or robotic flap pyeloplasty for recurrent UPJO with a long proximal ureteral stricture. Our surgical modifications included the “wishbone” anastomosis and “ureteral plate” technique. Demographic, perioperative, and follow-up data were recorded and compared retrospectively between the groups. Success was defined as subjective pain alleviation and hydronephrosis improvement. Results: Thirteen modified laparoscopic flap pyeloplasty (mLFP) and 8 modified robotic flap pyeloplasty (mRFP) were performed successfully without conversion. mRFP tended to have shorter overall operative time (142.4 vs. 179.1 min, p = 0.122) and anastomosis time (43.1 vs. 61.0 min, p = 0.093) than mLFP. No difference was found in estimated blood loss (p = 0.723) and pararenal draining time (p = 0.175) between the groups. The mean postoperative hospital stay of mRFP was significantly shorter than that of mLFP (5.0 vs. 8.2 days, p = 0.015). No major complications occurred. During the mean follow-up of 17.9 months, the overall success rate was 90.5%, and there was no significant difference between 2 groups. Conclusions: The modified flap pyeloplasty could be considered a practical and effective treatment option with a high success rate for recurrent UPJO with a long proximal ureteral stricture, and the robotic procedures showed advantages of higher efficiency and faster recovery.

To present our experience of laparoscopic and robotic ureteroplasty using onlay flap or graft for the management of long proximal or middle ureteral strictures and summarize our treatment strategies for these challenging scenarios. From March 2018 to January 2020, 53 patients with long proximal/middle ureteral strictures (2–6 cm) who underwent laparoscopic or robotic onlay flap/graft ureteroplasty were retrospectively enrolled. Different reconstruction techniques were chosen based on our management strategy: pelvic flap (PF) was the first choice for proximal stricture if pelvic tissue was sufficient for repair, while appendiceal flap (AF) was preferred over oral mucosa graft for both proximal and middle strictures. A total of 28 PFs, 9 AFs and 16 lingual mucosa grafts (LMGs) onlay ureteroplasty were performed successfully, with 33 laparoscopic procedures and 20 robotic procedures being undertaken. No intraoperative complications or conversion occurred. The median stricture length was 4 cm (range 2–6 cm). Compared with laparoscopic procedures, robotic procedures showed significantly shorter operative time (P = 0.008), shorter postoperative hospital stay (P = 0.011) but higher hospital cost (P

Objective To summarize the clinical characteristics and surgical management of adrenal teratoma in adults. Patients and Methods We retrospectively reviewed 14 patients with adrenal teratoma from January 2002 to June 2017, at 2 large centers in China and performed a systematic review of 39 patients from our series and published literatures. The clinicopathological characteristics, imaging features, surgical management and outcomes of this rare disease were analyzed. Results Our series includes 12 females and 2 males with the median age of 35. Seven patients were treated by open adrenalectomy (OA) and 7 by laparoscopic adrenalectomy (LA) without perioperative complications. All patients were alive without recurrence or canceration over a mean follow-up of 77.1 months. In the systemic review, the male-female ratio was nearly 1:3, with a median age of 29 years. Mean tumor size was 9.4 cm and the distribution was almost the same between left and right side (53.8% vs 46.2%). The most common symptoms were flank or abdominal pain (46.2%), whereas 53.8% patients were asymptomatic. Tumors were often cystic (63.9%) with intratumoral fat (91.7%) and calcifications (80.6%). All patients underwent surgery including 17 (43.6%) OA and 22 (56.4%) minimally invasive surgery. All tumors were pathologically confirmed mature teratoma except for one. Conclusion Adrenal teratoma is an extremely rare entity, frequently found to be large, benign and cystic. The patient's prognosis is generally good. As for its large volume, OA is the first choice for teratoma in most cases, while the LA can be an option in the small one.

We developed an in vitro DNA detection system using a pair of dCas9 proteins linked to split halves of luciferase. Luminescence was induced upon colocalization of the reporter pair to a ∼44 bp target sequence defined by sgRNAs. We used the system to detect Mycobacterium tuberculosis DNA with high specificity and sensitivity. The reprogrammability of dCas9 was further leveraged in an array design that accesses sequence information across the entire genome.