Volume 124  ·  Issue 09  ·  2011

Over the past decaade, more and more patients diagnosed as prostate cancer have received radical management attributing to the advent of prostate-specific antigen (PSA) based medical screening.Radical prostatectomy (RP) and radiation therapy (RT) are the most commonly used forms of definitive therapy for clinically localized prostate cancer.However, despite these technique advances, biochemical recurrence (BCR),as determined by subsequent rises in the serum PSA level,is still a challenge that urologists face。

Abstract：Background The 12th rib is an important anatomic marker in the process of percutaneous renal surgery; while the previous models without ribs can not provide close simulation conditions to human upper abdomen. To facilitate the learning and training of percutaneous renal access and intrarenal procedures under ultrasound and fluoroscopy guidance, we reported a biological bench model for percutaneous renal surgery. Methods The model was developed using an ex vivo porcine kidney with a longer than 3 cm ureter, a flap of full thickness of thoracic wall with skin, subcutaneous fascia, muscle and two ribs, as well as the standard equipment for percutaneous nephrolithotomy. The porcine kidney with a catheterized ureter was placed within the porcine flap and fixed to a wooden board with two long steel nails. Afterward, contrast medium or physiological saline (0.9% sodium chloride solution) was injected through the ureter, and the urinary system was examined with a fluoroscopy unit or an ultrasound. Artificial stone material was implanted in the renal pelvis. After practicing, the model could be dissected for kidney examination and a technical analysis. Results The advantage of this model was simple to set up and inexpensive, by using widely available material. The biological bench model can be employed for percutanous renal access, tract dilation, nephroscopy, and stone disintegration in the training and learning of clinical practice. Imaging is feasible under fluoroscopic and ultrasound guidance. The kidney models were utilized in hands on courses with over 100 people, and 90.5% attendants rated the porcine kidney model for simulation of percutaneous renal surgery as 'very helpful" or "helpful". Conclusion This biological training model simulates realistically the clinical procedure of percutaneous nephrolithotomy under fluoroscopic and ultrasound guidance。

Abstract：S:Background Seroma formation is one of the most common complications after breast cancer surgery. Various risk factors have been evaluated for their associations with the development of seromas in Western populations. However,similar data are not available in Chinese series. Therefore, we sought to investigate the potential risk factors for Chinese breast cancer patients.Methods A prospective study of female breast cancer patients undergoing surgery was carried out in Cancer Hospital of Fudan Unversity, Shanghai, China. Univariate analyses were performed by chi-square test or Student's t test or Mann-Whitney test and multivariate analyses by stepwise Logistic regression. The logistic model included age (years),total serum protein concentration (g/L), drainage volume on postoperative day 3 (POD 3; ml) and time to daily drainage volume not more than 30 ml (TTV30; days).Results A total of 158 patients with breast cancer were studied. The mean age at diagnosis was (52.14±10.77) years (range 25-92). During the follow-up period, 24 (15.2%) patients developed seromas. Calculated as continuous variables in the stepwise Logistic regression, age (OR=1.090, 95% CI 1.028-1.155, P=0.004), total serum protein concentration (OR=0.886, 95% Cl 0.791-0.992, P=0.036), drainage volume on POD3 (OR=1.013, 95% CI 1.002-1.023, P=0.017) and TTV30 (OR=1.273, 95% CI 1.039-1.561, P=0.020) were independent risk factors for seroma formation. Additionally,significant difference in daily drainage volume was substantiated in the analysis by seroma formation (P=0.034) rather than by type of surgery (P=0.713).Conclusions Although the pathogenesis of seroma remains controversial, such risk factors as age, nutritional status,drainage volume on POD3 and TTV30 should be considered for prediction and prevention of seroma formation in Chinese breast cancer patients。

Abstract：Background Living donor kidney transplantation (LKT) has been booming in China. This study aimed to elucidate the renal function of both Chinese donors and recipients after the donation and transplantation.Methods One hundred and forty-one pairs of donors and recipients for LKT were randomly selected and followed up for up to seven years. The donors' and recipients' renal function was recorded before and after operation.Results The donors presented a mean age of (43.9±7.5) years at donation. The female contributed 101/141 (71.6%) in all donors, and no effect was shown between genders on healthy donors' renal function. The donors' glomerular filtration rates (GFR) were (119.5±20.4) ml/min, (85.2±17.6) ml/min, (87.2±15.9) ml/min, (82.1±14.6) ml/min and (83.0±13.7)ml/min preoperatively, and for five days, three months, one year and beyond one year after the operation. The donors for the period of 1-3 years, 3-5 years and more than 5 years after donation showed GFR as (83.9±12.7) ml/min, (83.0±17.6)ml/min, and (80.9±20.8) ml/min, respectively, no statistically significant difference was found. Moreover, no significant clinical changes in blood pressure and proteinuria were found among the donors. In the recipients, delayed graft function (DGF) rate was 6.4%, acute rejection rate was 11.3%, and GFR were (66.5±16.4) ml/min, (73.2±19.6) ml/min and (63.9±18.6) ml/min respectively at three months, one year and beyond one year post-transplantation respectively.Conclusion The donors/recipients of LKT in Chinese population experience well-functioning remaining/donor kidneys。

Abstract：Background As the third-generation tension-free tape for female stress urinary incontinence (SUI), tension-free vaginal tape (TVT)-Secur has decreased the common complications associated with TVT and tension-free vaginal tape-transobturator (TVT-O), such as bladder perforation and obstruction of the bladder outlet; but its efficacy and persistence were still controversial. The aim of this study was to prospectively evaluate and compare the postoperative efficacy and complication at different follow-up time.Methods Patients with SUI, who underwent lVT-Secur treatment in two hospitals from October 2008 to October 2009,were selected. By analyzing preoperative and intraoperative data and postoperative complications, the therapeutic effect and satisfaction at different follow-up stages were evaluated.Results A total of 30 female patients participated in this study. Patients were scheduled for follow-up at the 1st month,3rd month, 6th month and 12th month, while the cure rate was 83.3% (25 patients), 66.7% (20 patients), 63.3% (19patients) and 60.0% (18 patients) respectively and the overactive bladder (OAB) symptoms appeared in 11 patients (36.7%), 10 patients (33.3%), 6 patients (20%) and 7 patients (23.3%) respectively.Conclusion With the follow-up time becoming longer, TVT-Secur has a high recurrence rate of SUI, the therapeutic effect from the 3rd month to the 12th month is relatively persistent。

Abstract：Background A growing number of studies worldwide have advocated the replacement of whole-breast irradiation with accelerated partial breast irradiation using three-dimensional conformal external-beam radiation (APBI-3DCRr) for early-stage breast cancer. But APBI can be only used in selected population of patients with early-staged breast cancer. It is not replacing the whole breast radiotherapy. This study aimed to examine the feasibility and acute normal tissue toxicity of the APBI-3DCRT technique in Chinese female patients who generally have smaller breasts compared to their Western counterparts.Methods From May 2006 to December 2009, a total of 48 Chinese female patients (with early-stage breast cancer who met the inclusion criteria) received APBI-3DCRT after breast-conserving surgery at Sun Yat-sen University Cancer Center. The total dosage from APBI-3DCRT was 34 Gy, delivered in 3.4 Gy per fractions, twice per day at intervals of at least six hours. The radiation dose, volume of the target area and volume of irradiated normal tissues were calculated.Acute toxicity was evaluated according to the Common Toxicity Criteria (CTC) 3.0.Results Among the 48 patients, the planning target volume for evaluation (PTVE) was (90.42±9.26) cm3, the ipsilateral breast volume (IBV) was (421.74±28.53) cm3, and the ratio between the two was (20.74±5.86)%. Evaluation of the dosimetric characteristics of the PTVE revealed excellent dosimetric results in 14 patients and acceptable results in 34 patients. The dose delivered to the PTVE ranged from 93% to 110% of the prescribed dose. The average ratio of the volume of PTVE receiving 95% of the prescription dose (V95) was (99.26±0.37)%. The habituation index (HI) and the conformity index (CI) were 1.08±0.01 and 0.72±0.02, respectively, suggesting good homogeneity and conformity of the dose delivered to the target field. The radiation dose to normal tissues and organs was within the dose limitation.Subjects experienced mild acute toxicity. The main manifestations were breast edema in 22 patients, breast pain in 7,skin erythema in 25, general malaise in 22 and cytopenia in 8. No acute radiological cardiac or pulmonary injury was found.Conclusions The results of our short-term follow-up showed that it is feasible to perform APBI-3DCRT for early-stage breast cancer after breast-conserving surgery in Chinese female patients with smaller breasts. However, further studies are required to elucidate its efficacy and long-term side effects。

Abstract：Background Various etiologies that contribute to the loss of pregnancy have been proposed. Despite the lack of established and uniform screening methods for recurrent pregnancy loss (RPL), there are several factors considered to be definite (or probable) causes of RPL. Data describing the etiological characteristics of RPL consist almost entirely of Caucasian populations. As we were interested in the Chinese population, the goal of this study was to determine the etiological characteristics of RPL in the Chinese patients.Methods The study was performed retrospectively by analyzing 1122 women with RPL. Patients were divided into three groups according to their number of pregnancy losses. Diagnostic tests included the following 9 critiria: parental genetics, uterine anatomy, autoimmune factors, alloimmune factors, thrombophilic factors, endocrine parameters, genital infection, toxoplasma, rubella, cytomegalovirus, herpes (TORCH) titers and RH blood groups. The criteria for abnormal results were defined before diagnosis.Results We found that 87.1% (977/1122) patients had no more than 3 abnormal aspects, and the proportion of total abnormal results was similar among groups. The prevalence of abnormal results for each test did not differ among groups,except in the cases of parental genetics, uterine anatomy and presence of mixed lymphocyte reaction blocking antibodies (MLR-Bf). Absence of MLR-Bf, as well as abnormally increased levels of CD3+CD19+ and CD56+CD16+ cells, was commonly detected in Chinese RPL patients.Conclusion Immunological disorders play an important role in RPL among Chinese patients。

Abstract：Background The primary ovarian sarcoma is a very rare malignancy. The objective of this study was to further investigate the clinicopathologic features and outcome in patients with primary sarcoma of the ovary.Methods Between 1988 and 2007, 24 patients with primary ovarian sarcoma who underwent treatment at Peking Union Medical Hospital were reviewed retrospectively. Response to treatment, progression and overall survival were analyzed.Results Patients with ovarian sarcoma had a mean age of (54.3±10.3) years, and 16 of them were postmenopausal.The most common symptom was abdominal pain, present in 14 patients. Of the 24 patients, 16 patients were pathologically diagnosed as carcinosarcoma (known as malignant mixed mesodermal tumor (MMMT)), 2 as ovarian leiomyosarcoma (LS) and 6 patients as ovarian endometrial stromal sarcoma (ESS). The patients in optimal debulking group had a median survival period of 28 months and 1-year survival rate of 71%. The patients in suboptimal debulking group had a significantly lower median survival of 6 months (P=-0.02) and 1-year survival rate of 29%. Among the patients,23 patients received chemotherapy and most of regimens were based on platinum, 3 patients received chemoradiation.The mean number of courses of combined chemotherapy was 6.6±5.0, and the response was unsatisfactory. The median survival for the entire group was 18.7 months. The one-year survival rate was 58%, and two-year survival rate only 29%.Conclusions Ovarian primary sarcoma has a poor overall prognosis. Optimal debulking surgery appears to be of prognostic significance. There is a clear need for further study to explore the role and the regimen of platinum-based chemotherapy in primary ovarian sarcoma。

Abstract：Background Adenomyoma is a very serious disease which influence the quality of life and leads to the infertility, and hysterectomy at the end. Unfortunetly, we still have no effective way to treat this kind of diseases. This study was aimed to evaluate the efficacy and surgical characteristics of modified adenomyomectomy.Methods This is a retrospective study and the subjects were collected in the past 5 years. We divided the subjects by the two different surgical procedures. Cases of adenomyoma patients who underwent conservative surgery, modified adenomyomectomy or wedge resection of the adenomyoma lesion were distributed to two groups retrospectively.Surgical characteristics, symptom relief, and recurrence were analysed in each group.Results General characteristics, including operation time, blood loss, and postoperative complication were similar in both groups. In the modified adenomyometomy group, the median follow-up time was 27.6 months and the rate of relief of dysmenorrhea and menorrhagia symptoms were 91.2% and 40.0%, respectively. In the wedge resection group, the rate of reliefe of dysmenorrhea and menorrhagia symptoms were 88.9% and 50.0%, respectively. Patients in both groups had statistically significant symptom relief, but there was no statistical difference between them. During the following time,ultrasonography relapse rate in modified modified adenomyomectomy group is significantly lower than the wedge resection group 15.0% vs. 69.2% (P ＜0.001). The relapse rate, in terms of symptoms, was 5.0% in the modified adenomyomectomy group, which was similar to the relapse rate in the wedge resection group. In terms of reproductive outcome, 33.3% of the patients with infertility complications in the modified adenomyomectomy group became pregnant.Among them, the rate of pregnancy by assisted reproductive techniques was 45.5%, which was significantly higher than the rate of natural pregnancy, 23.1% (P=0.039).Conclusion Modified adenomyomectomy appears to be a safe and effective operative method that shows advantages in reducing the rate of relapse after surgery。

Abstract：Background OGR1 was found as a G-protein coupled receptor (GPCR) and proton sensor. Our previous studies have found that OGR1 has inhibitory effect on the metastasis of prostate cancer. In order to investigate the roles of OGR1 gene in the biological activities of ovarian cancer, we studied the OGR1 effects on ovarian cancer cells, HEY cells.Methods OGR1 gene was transfected into HEY cell, in which endogenous expression is low. OGR1-overxepressed cells and vector-transfected cells were compared in different assays. Western blotting was employed to confirm the high expression level of OGR1. Cell proliferation was determined by MTT assay and cell doubling time assay. Cell migration assay (transwell assay) and cell adhesion assay were performed to determine the migration and adhesion potential of cells. Student's t test was employed for statistical analysis.Results Proliferation of OGR1-overexpressed cells was significantly reduced (P ＜0.01); cell migration was significantly inhibited in the OGR1-transfected cells (P ＜0.01); cell adhesion to extracellular matrix including fibronectin, vitronectin,collagen Ⅰ/Ⅳ was significantly increased (P ＜0.01).Conclusions OGR1 expression in human ovarian cancer cells significantly inhibited the cell proliferation and migration,but significantly enhanced cell adhesion to the extracellular matrix. It indicated that OGR1 may be a tumor suppressor gene for ovarian cancer。

Abstract：Background Hepatitis C virus (HCV) constitutes a major public health issue around the world, especially in developing countries like Pakistan. In this study, we assessed outcome of interferon (INF) treatment in chronic hepatitis C patients categorized by gender, age, and viral load.Methods In this study, 750 HCV positive patients with genotype 3 were selected, out of which 616 completed the entire treatment. Their personal history, pro-treatment HCV RNA and serum alanine transaminase (ALT) was quantified.Patients were treated with combination therapy of INF-α 2b three million units (thrice a week) plus ribavirin (1000-1200mg per day) for 24 weeks. After 24 weeks their HCV RNA and serum ALT level was quantified.Results Out of the 616 patients, 391 (63.5%) responded to therapeutic regimen (INF-α 2b plus ribavirin). Among the responders, 27.1% were men and 36.4% were women. Best treatment response was observed in patients having Iow viral load ＜8×105 IU/ml and age ≤40 years than patients having Iow viral load and age ＞40 years (73.2% vs. 60.3%, P=0.05).Conclusions Better response to IFN-α 2b plus ribavirin was observed in patients with lower viral RNA and younger age.It suggests that all patients considered for treatment should have quantification of serum HCV RNA level. The result can be used to counsel patients on the likelihood of response and may influence the patient's decision on treatment。

Abstract：Background Although cardiac resynchronization therapy (CRT) is already an established treatment, the characteristics of patients who have an excellent response to CRT and those who get no benefit remain to be determined. The purpose of this study was to search for potential predictors of both non-response and super-response to CRT.Methods Seventy-six consecutive patients who received CRT treatment were divided into group A (non-responders),group C (super-responders) and group B (responders exclusive of super-responders). Student's t test, Mann-Whitney test, Logistic regression and receiver operating characteristic curve were employed to identify potential predictors among the patients' demographic characteristics, clinical features, several electrocardiographic parameters before and after CRT implantation, and their pre-implant echocardiographic parameters.Results Group A had the lowest 3-month left ventricular ejection fraction (LVEF). Group C had the smallest pre-implant left ventricular end-diastolic dimension (LVEDD), the shortest post-implant QRS duration, the smallest 3-month LVEDD and the highest 3-month LVEF. In addition, there was a trend of gradual change in percent of left bundle branch block,severity of pre-implant mitral regurgitation, pre-implant QRS dispersion, post-implant QRS duration as well as post-implant QRS dispersion from group A to group B and from group B to group C. Multivariable Logistic analysis revealed that only pre-implant LVEDD could predict CRT super-response. A pre-implant LVEDD of 68.5 mm was the cut-off value that identified super-responders with 87.5% sensitivity and 79.7% specificity. A pre-implant LVEDD of 62.5mm identified super-responders with 50.0% sensitivity and 89.8% specificity.Conclusions Predictors of a CRT non-response remain unclear at present. But it is credible that patients with a smaller left ventricle would have a better chance to become super-responders to CRT。

Abstract：Background The pathological abnormalities of the AIDS patients lie in the subcortical regions of the brain, specifically the deep white matter and basal ganglia, while the extent of pathology generally correlates with the severity of cognitive impairments in the white matter and basal ganglia. Brain metabolite changes of these lesions can reflect the pathological abnormalities. The purpose of this study was to assess the value of magnetic resonance spectroscopy (MRS) in the diagnosis of cognitive impairment in AIDS patients.Methods 3.0T MR was used to measure N-acetyl aspartate (NAA), choline (Cho), myo-inositol (MI) and creatinine (Cr)in the frontal white matter, basal ganglia and parietal cortex of 21 AIDS patients with dementia complex (ADC), 19 AIDS patients with neuroasymptomatic (NAS) and 20 seronegative (SN) controls. Then we compared the difference of metabolic rate between AIDS patients and SN groups.Results NAA/Cr (mean=1.2502, SD=0.1600) was significantly decreased and Cho/Cr (mean=1.2028, SD=1.1655) was increased in the frontal white matter in ADC group, while NAA/Cr (mean=1.5334, SD=0.0513) was reduced in NAS group when compared with SN group. NANCr in the basal ganglia was decreased in both ADC and NAS groups (mean=1.2625,SD=0.1615 and mean=1.5278, SD=0.0380, respectively). Cho/Cr (mean=1. 1631, SD=0.0981) was markedly increased in ADC group. Although NAA/Cr, Cho/Cr and MI/Cr in the parietal cortex had a certain change in both ADC and NAS groups compared with SN group, the differences were not statistically significant.Conclusions The brain metabolite changes of AIDS patients are correlated with cognitive impairments. MRS can be used as a valuable inspection method to assess cognitive impairments in AIDS patients。

Abstract：Objective To summarize the risk stratification and current treatment strategies for acute myeloid leukemia (AML) and discuss the role of emerging novel agents that might be applied in future clinical trials.Data sources The data in this article were collected from PubMed database with relevant English articles published from 1991 to 2009.Study selection Articles regarding the risk stratification and therapeutic options of AML, as well as the characteristics of leukemic stem cells were selected.Results AML is a heterogeneous disease with variable clinical outcome dependent on several prognostic factors,including age, cytogenetics and molecular markers. The advances in the understanding of AML pathogenesis and development will generate potential novel agents that might improve the treatment results of standard chemotherapy.Conclusion Deeper insight into the multiple transforming events of AML may aid us in designing combinations of small molecule inhibitors based on the individual patient characteristics。

Abstract：Background Cryopreserved conduit valved homografts (CVH) have been widely used in surgical treatment of cardiac disease. This study aimed to determine the extent of host cell ingrowth and the durability and immunogenicity of CVH,and to compare the performance of CVH stored at 4℃ and CVH cryopreserved in liquid nitrogen at -196℃.Methods Heterotopic transplants of canine CVH stored at 4℃ (n=14) and cryopreserved in liquid nitrogen (n=14) were made onto the abdominal aorta of recipient dogs. Animals were sacrificed at 7 and 15 days and at 1, 3, 6, 9, and 12months after transplantation to excise the implanted CVHs. Tissue DNA extraction and quantitative polymerase chain reaction (PCR) were performed to calculate the ratio of donor cells and host cells in the CVH. The tissue viability of CVH after implantation was analyzed by detecting alkaline fibroblast growth factor 2 (FGF-2) using immunohistochemical staining and by observation under transmission electron microscope and scanning electron microscope.Results All the animals survived and recovered well. There were few repopulating host cells (0.04-0.83%) in the implanted CVH at 7 or 15 days. The ratio of ingrowing host cells into the CVH continued rising after implantation and reached 40%-47% in the 12th month postoperation. Histology, transmission electron microscopy and FGF-2immunohistochemical staining indicated that fibroblasts and the host's endothelial cells were the main cellular elements invading the CVH. There were no significant differences in results between CVH stored at 4℃ and CVH cryopreserved in liquid nitrogen.Conclusions Host cells growing into CVH are very important for maintaining the long-term structure and function of the implanted CVH. There is no significant difference between CVH storing at 4℃ or in liquid nitrogen in regard to the ingrowth of host cells or of morphologic features after CVH allografting。

Abstract：Background The non-Hodgkin's lymphoma is the AIDS symbol of tumor, with high incidence and poor prognosis. The purpose of this study was to investigate the radiological demonstrations of AIDS complicated by intestinal lymphoma and its pathological mechanism.Methods CT scan and pathological data of 3 cases of AIDS complicated by intestinal lymphoma were retrospectively analyzed. All the 3 cases received CT diagnostic scanning, including 2 receiving barium enema radiography after lower gastrointestinal tract cleansing, 1 receiving laporotomy to obtain partial thickened intestinal canal for histopathology and 1with autopsy for histopathological analysis.Results Intestinal canal lymphoma occurred at the left intestinal canal in 2 cases and at the right intestinal canal in the other case, with manifestations of unevenly thickened intestinal canal wall, narrowed canal lumen and filling defect. It was pathologically classified as B cell lymphoma.Conclusions AIDS complicated by B cell lymphoma has manifestations of unevenly thickened intestinal canal wall and narrowed canal lumen, which are non-specific. It should be differentiated from other tumors of intestinal canal in its diagnosis。

Abstract：Background The incidence of urinary lithiasis following kidney transplantation is very low, and decision-supporting data are not available. The aim of this study was to review the diagnosis and treatment of urinary lithiasis following kidney transplantation, which is of realistic significance to reduce urinary lithiasis following kidney transplantation, prolong the survival of renal allografts.Methods The incidence, diagnosis and treatment of urinary lithiasis in ten patients following kidney transplantation were analyzed retrospectively. Seven out of these patients had stones sized approximately 0.4-1.1 cm, and they were treated with low-voltage, low-frequency extracorporeal shock-wave lithotripsy (ESWL). Two patients had stones sized ＜0.3 cm and they underwent cystoscopy and ureteroscopy. The ureteral catheter endoscopes were inserted in a retrograde manner to mobilize stones repeatedly. After elimination of obstruction, a ureteral double J stent was indwelt.One patient had a pelvic stone (1.2 cm), which was removed surgically.Results The major clinical manifestations were hematuria, oliguria or anuria. Some patients were asymptomatic and they were diagnosed through laboratory tests and imaging examinations, e.g., ultrasonography. After elimination of obstruction, subjective symptoms disappeared in all patients, and the function of renal allografts recovered. A six-month follow-up indicated no remnant stones or lithiasis relapse.Conclusions The diagnosis and treatment of renal allograft lithiasis are challenging. After prompt and appropriate treatment, the prognosis was satisfactory, and permanent renal functional impairment did not occur in most patients。

Abstract：Renal angiomyolipoma is a type of benign tumor that occurs sporadically in addition to being associated with tuberous sclerosis. Preoperative embolization of large tumors is important to avoid excessive blood loss during surgery. We reported a patient with a 5505-g giant renal angiomyolipoma in a solitary kidney. The patient was treated with preoperative embolization and radical nephrectomy without complications. This type of treatment for an enormous angiomyolipoma can reduce the risk of uncontrolled hemorrhage caused by rupture of the tumor during the operation and should be considered for the treatment of similar tumors。

Abstract：After successful renal artery angioplasty and stent placement, a patient in a fully anticoagulated state developed hypotension and flank pain. Computed tomography (CT) of the abdomen revealed a large renal subcapsular haematoma which was successfully managed conservatively without embolotherapy and surgical intervention. To prevent hemorrhage after renal artery stenting, it is necessary to underscore the importance of reducing the contrast volume and pressure of angiography, controlling systemic blood pressure, and monitoring guide wire position at all times。

To the Editor: We read with a great interest the article by MEI Ju and colleagues1 having obtained outstanding early and mid-term clinical outcomes of type C pulmonary atresia with ventricular septal defect (PA-VSD) and major aortopulmonary collateral arteries (MAPCAs).This is a very interesting paper,proposing a new two-stage surgery technique on treating PA-VSD with MAPCAs.However, we had some questions about it。