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OPEN Preliminary comparison

of the modified extraperitoneal
free‑PORT single incision technique
and transabdominal multi‑incision
robot‑assisted laparoscopic radical
prostatectomy
Shangqing Ren 1,6*, Yong Ou 1,2,6, Yaoqian Wang 1,2,6, Yi Wei 1, Cheng Luo 1, Bo Yang 1,2,
Jiazheng Yuan 1, Qian Lv 1, Fang Zhou 1, Zhengjun Chen 1, Yu Nie 1, Jie Lin 3, Yilei Wu 4, Bo Yang 5,
Shida Fan 1* & Dong Wang 1*

To compare the clinical efficacy of an innovative modified single-incision technique without special
extraperitoneal PORT with that of transperitoneal multi-incision robot-assisted laparoscopic radical
prostatectomy and to explore the feasibility and safety of the former. A retrospective analysis was
performed on 259 patients who received robot-assisted laparoscopic radical prostatectomy in the
Robot Minimally Invasive Center of Sichuan Provincial People’s Hospital between September 2018 and
August 2021. Among them were 147 cases involving extraperitoneal single incision with no special
PORT (Group A) and 112 cases involving multiple incisions by the transperitoneal method (Group B).
Differences in age, PSA level, Gleason score, prostate volume, body mass index, clinical stage, lower
abdominal operation history, and lymph node dissection ratio between the two groups were not
statistically significant (P > 0.05). All operations were performed by the same operator. In this study,
all 259 operations were completed successfully, and there was no conversion. There was no significant
difference in transperitoneal blood loss, postoperative hospital stay, positive rate of incision margin,
indwelling time of urinary catheter, satisfaction rate of immediate urine control, satisfaction rate
of urine control 3 months after operation, positive rate of postoperative lymph node pathology
or postoperative pathological stage between the two groups (P > 0.05). There were significant
differences in operation time, postoperative exhaust time and incision length (P < 0.05). The modified
extraperitoneal nonspecial PORT single-incision technique is safe and feasible for robot-assisted
laparoscopic radical prostatectomy, and its curative effect is similar to that of transperitoneal multi-
incision RARP. It has the advantages of a short operation time, less impact on the gastrointestinal
tract and a more beautiful incision. The long-term effect of treatment needs to be further confirmed by
prospective studies.

Prostate cancer is one of the most common malignant tumours in the male genitourinary system. In 2020, there
were 1,414,259 cases and 375,304 deaths w
­ orldwide1. Epidemiological data show that the occurrence of prostate

1
Department of Robotic Minimally Invasive Surgery Center, Sichuan Academy of Medical Sciences and Sichuan
Provincial People’s Hospital, Affiliated Hospital of the University of Electronic Science and Technology of
China, Chengdu  610072, China. 2School of Medicine, University of Electronic Science and Technology of China,
Chengdu 610051, Sichuan, China. 3School of Computer Science and Engineering, University of Electronic Science
and Technology of China, Chengdu 611731, Sichuan, China. 4Department of Medical Records Statistics, Sichuan
Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu 611731, Sichuan,
China. 5Department of Paediatric Surgery, Sichuan Academy of Medical Sciences and Sichuan Provincial People’s
Hospital, Chengdu  610072, Sichuan, China. 6These authors contributed equally: Shangqing Ren, Yong Ou and
Yaoqian Wang. *email: rsq0516@163.com; 18523636523@163.com; wangdong_robot@163.com

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cancer has ethnic and family genetic tendencies, with the highest incidence in North America, the Caribbean and
people of African ­descent2. At present, the main treatments for prostate cancer include active monitoring, radical
surgery, endocrine therapy, radiotherapy and chemotherapy. Due to the high-definition magnified three-dimen-
sional imaging system, multijoint instrument arm, and 540-degree rotation of simulated wrist instruments, the
da Vinci robot system more easily shortens the urologist’s learning curve and reduces the difficulty of operation
than other approaches. The objectives are to achieve a more complete cure of the tumour, enable the maximum
degree of sexual function preservation and maximize the retention of urine control function. Although many
medical centres in the world have adopted robot-assisted laparoscopic radical prostatectomy (robotic assisted
laparoscopy radical prostatectomy, RARP) as the standard procedure for the treatment of prostate cancer, they
still face a series of complications in patients, such as loss of sexual function and urinary i­ ncontinence3–5.
The continuous update of the da Vinci robotic surgery-assisted system provides more opportunities for tech-
nological innovation in single-incision laparoscopy. Although special PORT equipment is often used to help solve
space constraints, it will add an additional economic ­burden6,7. To eliminate the dependence on special PORT
equipment, our centre has continually explored innovative extraperitoneal space techniques since November
2020 to implement the single-incision extraperitoneal nonspecial PORT modified RARP ­approach8. In this study,
the clinical data of 259 RARP patients receiving either a single incision without special extraperitoneal PORT or
multiple transperitoneal incisions in our centre between September 2018 and August 2021 were retrospectively
compared to analyse the feasibility and clinical efficacy of the modified technology.

Objects and methods
General information.  A total of 259 patients with RARP were enrolled in this study, and all operations
were performed by the same surgeon. Among the patients, there were 147 cases involving no special PORT
extraperitoneal single-incision RARP (Group A) and 112 cases involving multiple incisions by transperitoneal
method RARP (Group B). The study was approved by the Ethics Committee of Sichuan Provincial People’s Hos-
pital, and all subjects or their relatives signed informed consent forms.

The operation method.  Without special PORT extraperitoneal single‑incision RARP (Group A).  Channel
establishment.  With the patient in the Trendelenburg position after general anaesthesia, the lowest point of the
arc incision was taken from the anterior midline to 5 cm on the pubic symphysis, and 2.5 cm on both sides of the
7–8 cm midline from the pubic symphysis was used as the arc incision at both ends (Fig. 1A). The skin and sub-
cutaneous tissue were cut in turn, the space between the subcutaneous tissue and the rectus abdominis was fully
freed, and the skin flap was turned to the cephalic side and pulled. The anterior sheath of the rectus abdominis
was cut longitudinally at the midpoint of the incision at 7–8 cm from the pubic symphysis, 2.5 cm was extended
upwards, and the fingers were placed into the blunt separation of the rectus abdominis and the peritoneal space.
The extraperitoneal space was dilated with a homemade balloon, and 900 ml gas was injected into the balloon
for 10 s. The extraperitoneal space was examined, and a 12 mm trocar was placed close to the anterior sheath
incision (Fig. 1B). The anterior sheath of the rectus abdominis was sutured to maintain airtightness, the space
was inflated, and the lens was inserted for observation. The lower edge of the arc incision was pulled, the 12 mm
trocar was placed at 3–4 cm above the pubic symphysis under direct vision, both ends of the arc incision were
pulled, and two robotic metal puncture kits were placed at 3–4 cm on both sides of the midline (Fig. 1C). The da
Vinci Si robot-assisted laparoscopic surgery system was connected (Fig. 1D). The distal end was the lens hole,
and the proximal end was the auxiliary hole.

Operation procedures.  A 30-degree upwards visual field was used to expose the pubic symphysis area and
Retzius space, free and remove the fat on the surface of the prostate, cut open the bilateral intrapelvic fascia and
expose the deep dorsal vein complex of the penis (dorsal vascular complex, DVC) and pubic prostatic ligament.
The junction with the prostate bladder was separated and cut by monopolar electric scissors. After confirming
the posterior wall of the bladder neck and middle lobe of the prostate, the posterior wall of the bladder neck
was cut open, and the muscles between the base of the prostate and detrusor of the bladder were identified for
sharp separation to expose the vas deferens and seminal vesicles. The seminal vesicles were completely exposed
after the bilateral vas deferens were severed (Fig. 2). The Denonvilliers’ Fascia was cut, and the dorsal side of the
prostate was separated to the apex of the prostate. In all cases, the vascular nerve bundle was reserved. The lateral
ligament of the prostate was ligated with HEM-O-LOK and severed. The DVC was repeatedly sutured with 2-0
barbed wire, and the sutures were temporarily left uncut and placed on the left side of the gap. The urethra was
resected after dissociating the tip of the prostate, and the urethral length 1.5–2.0 cm was preserved. The blad-
der neck and urethra were anastomosed continuously with 2-0 double needle inverted needle thread from the
posterior lip of the bladder neck. A 20F three-cavity catheter was retained. The suture of the DVC was cut and
ligated after the water injection test, which showed that there was no urine leakage and no active bleeding. After
quitting the instrument, the prostate specimen was removed through an arc single incision, a plasma drain was
placed at the site of the vesicourethral anastomosis, and the incision was sutured layer by layer.

Multiple incisions by transperitoneal method RARP (Group B).  Channel establishment.  After general anaes-
thesia, the disposable 12 mm cannula was placed on the upper edge of the navel, and the robot laparoscope
was placed. Under direct vision, an 8 mm robotic metal cannula was placed 1.5–2.0 cm below the level of the
paraumbilical region of the right left lateral rectus abdominis and 8–10 cm from the lens hole. The No. 1 and No.
2 mechanical arms were placed.
The 8 mm casing was placed 1.5–2.0 cm above the No. 2 manipulator, and the No. 3 manipulator was placed
on the left axillary front line of the No. 2 arm 8–10 cm. The 12 mm cannula was placed as the helper hole 4 cm

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Figure 1.  Establishment of a single-incision RARP channel with a modified extraperitoneal technique.

Figure 2.  The seminal vesicles were completely exposed after the bilateral vas deferens were severed.

on the right side of the umbilical plane lens hole and 4 cm on the outside of the right mechanical arm, and the
operation was performed using a transperitoneal approach (Fig. 3).

Operation procedures.  First, the seminal vesicle gland and vas deferens were dissociated, the Dirichlet space
was established, and the space was filled with gauze as a mark. With the inverted U-shaped peritoneal incision
along the median umbilical ligament, the anterior bladder space was entered, the fascia around the prostate and
as far as the tip was freed, the intrapelvic fascia was opened, both sides of the prostate were dissociated until the

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Figure 3.  “A” shows a lens cannula, “B” shows a No. 2 arm cannula, “C” shows a No. 3 arm cannula, “D” shows
a No. 1 arm cannula, “E” shows an incision for removing a specimen with a transperitoneal approach, “F and G”
show auxiliary cannulas, and “H” shows an incision through an extraperitoneal single-hole pathway.

deep dorsal vein complex (dorsal vein complex, DVC) was clearly exposed, and the pubic prostatic ligament
was retained. After amputation of the bladder neck (Fig. 4), the lateral prostatic ligament was dissected, and the
bilateral ligament was ligated. All of them were tied to preserve the neurovascular bundle at the tip of the pros-
tate. The prostate was completely removed after cutting the DVC with 2-0 absorbable sutures. After the bladder
neck was anastomosed to the urethra, a 20F three-lumen catheter was retained. After ensuring that there was no
water leakage at the anastomosis, the specimen was removed from the instrument, a plasma drain was placed at
the site of the vesicourethral anastomosis, and the incision was sutured layer by layer.

Observation index.  The operation time, intraoperative blood loss, postoperative hospital stay, postopera-
tive exhaust time, positive rate of incisal margin, indwelling time of urinary catheter, erectile function, immedi-
ate urine control satisfaction rate (24 h using urine pad was ≤ 1 as urine control satisfaction rate), postoperative
3-month urine control satisfaction rate, postoperative lymph node pathology, incision length and biochemical
recurrence rate were compared between the two groups.

Statistical methods.  SPSS 21.0 software was used to input and analyse the data. Age, operation time, post-
operative hospital stay, postoperative exhaust time, catheter indwelling time and incision length were observed
to be in accordance with a normal distribution, expressed as “x ± s,” and compared between the two groups by
independent sample t test. PSA, prostate volume and intraoperative bleeding volume had skewed distributions,
expressed by M (Q1 and Q3), and the Mann‒Whitney U test was used to compare the two groups. The adop-
tion rate/constituent ratio, frequency of classified data such as Gleason score, BMI, clinical stage, pathological
stage, history of lower abdominal operation, lymph node dissection, positive cutting edge, preservation of erec-

Figure 4.  Amputation of the bladder neck.

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tile function after operation, satisfactory urine control immediately after operation, satisfactory urine control
3 months after operation, positive lymph node pathology and biochemical recurrence 3 months after operation
(PSA was higher than 0.2 ng/mL), and chi-square test were used to compare between groups (two-sided test,
test level α = 0.05).

Declaration.  This study complies with the principles of the Helsinki Declaration and the relevant ethical
requirements of Sichuan Academy of Medical Sciences and Sichuan Provincial People’s Hospital (ethics No. 100,
2020).

Results
In this study, all 259 operations were completed successfully, and there was no conversion. There was no sig-
nificant difference in age, PSA level, Gleason score, prostate volume, body mass index (BMI), clinical stage,
history of lower abdominal operation or proportion of lymph node dissection between the group A and group
B. General information is shown in Table 1. The observation indexes of group A and group B were as follows,
respectively: the intraoperative bleeding volume was 119.35 (50.0–180.0) ml and 116.43 (50.0–200.0) ml; the
postoperative hospital stay was 10.18 (6.0–15.0) days and 9.8 (5.0–23.0) days; the number of patients with posi-
tive incision margins was 20 (13.6%) and 18 (16.1%); the postoperative indwelling times of the urinary catheter
were 8.23 (5.0–14.0) days and 8.25 (5.0–15.0) days; the postoperative erectile function was preserved in 16 cases
(10.9%) and 15 cases (13.4%); the number of satisfactory cases of immediate urinary control after operation
was 88 (60.5%) and 60 (53.6%); the number of satisfactory cases of urinary control 3 months after the operation
was 133 (90.5%) and 102 (91.1%); the number of pathologically positive cases of postoperative lymph nodes
was 1 case (0.7%) and 0 cases (0%). Three months after the operation, the number of biochemical recurrence
or persistent PSA status was 5 (3.4%) and 3 (2.7%). The numbers according to postoperative pTNM stage were
as follows, respectively: pT2: 137 (93.2%), 105 (93.7%) and pT3a: 10 (6.8%), 7 (6.3%). There was no significant
difference in the above indexes (P > 0.05). The operation times, respectively, were 132.63 (80.0–200.0) min and
143.82 (100.0–202.0) min; the postoperative exhaust times were 2.88 (2.0–4.0) d and 1.3 (1.0–4.0) days. The
incision length was 5.32 (4.1–6.5) cm and 8.07 (6.5–9.0) cm, respectively, and the above indicators were statisti-
cally significant (< 0.05). Single-incision RARP without special extraperitoneal PORT was superior to traditional
transperitoneal multi-incision RARP in operation time, postoperative exhaust time and incision aesthetics. The
results are shown in Table 2.

Discussion
Since urology single-hole laparoscopy was introduced into China in 2008, it has experienced different periods
of development in the urinary field, while the development of a special multichannel device, namely, commer-
cial PORT, has promoted the development of single-hole technology. However, due to the disappearance of the
operating triangle of the main instrument, the impact of endoscopy with other instruments during the operation
still limits the popularization of this technique to a great extent. At present, the development of single-hole tech-
nology in China is becoming increasingly stable, and the surgical robot system has brought a new development
direction for urologists. Professor Ren gave full play to the high flexibility and fine operation ability of the robot
system in 2018 and completed the first single-hole RARP in A ­ sia9.
To solve the problem of instrument collision, foreign experts and scholars actively explores new solutions.
From a homemade single-hole casing for early gloves to a commercial single-hole special casing R-port, SILS

Group A (n = 147) Group B (n = 112) P

Age, years, mean (SD) 71.05 (7.82) 70.89 (7.30) 0.871
BMI, kg/m2, mean (SD) 23.60 (3.69) 23.38 (3.07) 0.598
Preoperative serum total PSA, ng/mL, mean (SD) 22.21 (20.22) 24.67 (20.17) 0.332
Prostate volume, mL, mean (SD) 47.16 (25.92) 49.00 (22.91) 0.554
Gleason score 0.647
 6 20 (13.6%) 21 (18.8%)
 7 77 (52.4%) 46 (41.1%)
 8 16 (10.9%) 31 (27.7%)
 9 34 (23.1) 14 (12.5%)
cTNM stage, n (%) 0.352
 cT1c 1 (0.7%) 3 (2.7%)
 cT2a 27 (18.4%) 30 (26.8%)
 cT2b 50 (34.0%) 27 (24.1%)
 cT2c 62 (42.2%) 47 (42.0%)
 cT3a 7 (4.8%) 5 (4.5%)
History of lower abdominal operation 7 (4.8%) 6 (5.4%) 0.976
Proportion of lymph node dissection, n (%) 7 (4.8%) 5 (4.5%) 0.910

Table 1.  General information. BMI body mass index, SD standard deviation.

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Group A (n = 147) Group B (n = 112) P

Operative time, min, mean (SD) 132.63 (32.17) 143.82 (26.47) 0.003
Estimated blood loss, mL, mean (SD) 119.35 (23.62) 116.43 (33.92) 0.437
Open conversion, n (%) 0 (0%) 0 (0%)
Postoperative hospital stay, days 9.80 (2.89) 10.18 (2.15) 0.232
Postoperative exhaust time, days 1.87 (0.772) 2.88 (0.64) 0.000
Positive lymph nodes, n (%) 1 (0.7%) 0 (0%) 0.252
Positive surgical margin, n (%) 20 (13.6%) 18 (16.1%) 0.579
Postoperative indwelling time of urinary catheter, days 8.23 (1.84) 8.25 (1.70) 0.933
pTNM stage, n (%) 0.125
 pT2 137 (93.2%) 105 (93.7%)
 pT3a 10 (6.8%) 7 (6.3%)
Postoperative erectile function, n (%) 16 (10.9%) 15 (13.4%) 0.539
Immediate urinary control after operation, n (%) 88 (60.5%) 60 (53.6%) 0.312
Urinary control 3 months after operation, n (%) 133 (90.5%) 102 (91.1%) 0.870
Biochemical recurrence or persistent PSA status after 3 months, n (%) 5 (3.4%) 3 (2.7%) 0.740
Incision length, cm 5.32 (0.56) 8.07 (0.48) 0.000

Table 2.  Comparison of postoperative efficacy of patients (cases). A PSA above 0.2 ng/ml at 3 months

postoperatively was defined as biochemical recurrence or persistent PSA status. Erectile function was defined
as a patient’s postoperative IIEF scale score greater than 12 and most of the time being able to complete sexual
life. SD standard deviation.

Port, QuadPort, TriPort, LagiPort and so on, special endoscopic operation platforms and instruments were
developed, which solved the problem of mutual interference of single-hole instruments to a certain extent.
The progress of minimally invasive technology has also prompted domestic and foreign experts and scholars
to constantly explore the comparison of the clinical effects of RARP under various new technologies. Since
November 2020, to eliminate the dependence on PORT and reduce the cost of treatment, our centre began to
try a modified extraperitoneal technique, that is, a single incision extraperitoneal technique without a special
PORT. In this study, there was no significant difference in intraoperative blood loss, postoperative hospital stay,
postoperative exhaust time, positive rate of incisal margin, indwelling time of urinary catheter, postoperative
erectile function, immediate postoperative urine control satisfaction rate, postoperative 3-month urine control
satisfaction rate or postoperative 3-month biochemical recurrence or persistent PSA status rate between the
modified extraperitoneal technique and traditional transperitoneal RARP, which was consistent with the results
of previous foreign s­ tudies10,11.
The latest research results show that there is no significant difference in perioperative and pathological results
between single-incision RARP and standard laparoscopic multiple-incision RARP. Some studies have reported
that single-incision surgery may have more advantages in the recovery of postoperative erectile ­function12–14, but
there are also reports that single-incision surgery takes a longer time because of the establishment of s­ pace15,16.
This is because although the robot system multijoint instrument arm and simulated wrist instrument improve the
problem of too narrow operation space to some extent, the collision between robotic arms will still occur during
placement of a slightly large free suture, which also makes it more difficult for assistants to cooperate. Previous
studies suggest that compared with traditional transperitoneal multi-incision RARP, single-incision extraperi-
toneal RARP has a shorter hospitalization time, less demand for postoperative painkillers and anaesthetics, and
a considerable incidence of postoperative complications and readmission r­ ate17. Some studies suggest that the
use of the da Vinci SP platform operation can classify RARP as daytime surgery and can reduce or avoid the
use of analgesics. Short-term function and oncology results are not significantly different compared to routine
­hospitalization18. Some scholars believe that the single-incision scar has the highest score in terms of psychosocial
impact and aesthetics, which will have a great impact on the quality of life of ­patients19,20.
Transperitoneal RARP can delay the recovery of digestive tract function due to interference with the gastro-
intestinal tract and even has the possibility of postoperative intestinal obstruction and abdominal adhesion, so
previous abdominal surgery is a relative c­ ontraindication21, while the extraperitoneal approach can expand the
scope of surgical indications on the premise of a good cosmetic effect and reduce incision pain. However, due to
the significant regional differences in the incidence of prostate cancer in China and the imbalance of diagnosis
and treatment levels and economic conditions in different regions, minimizing the medical expenses of patients
is also one of the goals pursued by surgeons on the premise of minimal invasiveness. Therefore, the modified
technology in this study was intended to eliminate the restrictions of PORT. The results show that this technol-
ogy is a new surgical method worthy of implementation; this approach also makes up for the disadvantage that
the development of single-incision technology is restricted by the lack of special PORT equipment in some
medical institutions.
At present, the modified methods of RARP are also diversified, and the latest research is mainly focused
on different approaches to retain R ­ etzius22–26. The results suggest that RS-RARP (Retzius sparing) had bet-
ter postoperative continence recovery than C-RARP (traditional), while sexual function recovery rates were

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not significantly different. There were also no significant differences in operation time, intraoperative blood
loss, length of stay, positive margin rate or c­ omplications22. Additionally, a report showed that compared with
C-RARP, RS-RARP showed better recovery of continence, shorter console time, and a lower incidence of hernia.
Although there was no significant difference in overall PSM, we suggest that the surgeon should be more careful
­ rostate23. However, some studies are also controversial. RS-RARP improves early
if the lesion is in the anterior p
urinary continence recovery compared to anterior RARP, with this advantage being lost after 3 to 6 months.
However, erectile function and quality of life were comparable between the two techniques. The results concern-
ing the rate of positive margins remain controversial. Future studies with longer follow-up are needed to better
assess oncologic o ­ utcomes24. The application of a transvesical approach to RARP for localized PCa could obtain
promising outcomes in terms of postoperative UC recovery. In addition, surgical strategies encompassing the
nerve-sparing technique and the Retzius-sparing procedures during RARP, namely, the transvesical or posterior
approach, could independently enable early achievement of postoperative c­ ontinence25.
At the same time, this study has some limitations. First, subjective factors interfere with the selection of
patients in the retrospective study. Second, the modified technique group was completed on the experience of
the transperitoneal group, and the surgical experience was more abundant for the chief surgeon when operat-
ing on patients in the extraperitoneal group than when operating on patients in the transperitoneal group. This
may be one of the reasons for the difference in operation time. Finally, the extraperitoneal single-hole technique
limits the scope of standard pelvic lymph node dissection. In this study, obturator lymph node dissection was
performed in the extraperitoneal single-hole group, and standard pelvic lymph node dissection was performed
in the transperitoneal group. The results showed that 1 case (0.7%) was positive in the extraperitoneal single-
hole group, and there was no significant difference between the extraperitoneal group and the transperitoneal
group. Therefore, in the future, prospective control studies are still needed for verification, and we also need to
find better methods to expand the surgical space and scope of operation.
It is worth noting that there is a possibility of peritoneal rupture leading to failure of space establishment at
the initial stage of learning from the extraperitoneal single incision channel, but the problem will be resolved
as experience accumulates.
Single-incision robot-assisted laparoscopic radical prostatectomy without a special PORT is safe and feasible,
and its curative effect is similar to that of the traditional multiple-incisions approach, with the advantages of a
short operation time, less influence on the gastrointestinal tract and a more beautiful incision. The long-term
effect of treatment needs to be further confirmed by prospective studies.

Date availability
The raw data supporting the conclusions of this article will be made available by the authors without undue
reservation. Please contact the author Yong Ou (email: 675893648@qq.com).

Received: 6 April 2022; Accepted: 17 January 2023

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Author contributions
Conception and design: D.W., S.R., Y.O., and Y.W. Acquisition of data: D.W., S.R., Y.O., Y.W., B.Y., C.L., J.Y., and
F.Z. Analysis and interpretation of data: D.W., S.R., Y.O., Y.W., Q.L., S.F. and Z.C. Statistical analysis: J.L., Y.W.
and B.Y. Manuscript writing: Y.W. and J.L. Manuscript editing: Y.O. and S.R. All authors contributed to the article
and approved the submitted version.

Funding
This study is supported by Key Research and Development Projects of Sichuan Science and Technology Depart-
ment (2022YFS0135) and "The General Item of Medical Engineering Cross" (serial number ZYGX2021YGLH011)
of Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China.

Competing interests 
The authors declare no competing interests.

Additional information
Correspondence and requests for materials should be addressed to S.R., S.F. or D.W.
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