BACKGROUND:Cyclosporine A has shown its immunosuppressive effects and has been widely used in clinical organ transplantation.OBJECTIVE:To review the recent studies on the immunosuppressive mechanisms and the active pathway of cyclosporine A.RETRIEVAL STRATEGY:A compute-based online search of ScienceDirect Onsite,ProQuest,Springer and Ovid,based on the data from Peking University Medical Library,was undertaken for the English articles concerning with the immunosuppressive mechanism of cyclosporine A from January 1990 to December 2006,with the keywords of "cyclosporine A,mechanism/action,immunosuppression".Totally 68 articles were collected after the first trial,and the preliminary screening was conducted for the titles and abstracts.Inclusion criteria:articles related with the immunosuppressive mechanisms of cyclosporine A.Repetitive studies were excluded.Fifty accorded with the inclusive criteria,and 46 of them regarding tracheal transplantation were selected for the full-texts as the references.LITERATURE EVALUATION:Forty-six included articles included 6 ones about the clinical use and effects of cyclosporine A,and 40 involving the related studies on the molecular mechanisms of cyclosporine A.DATA SYNTHESIS:The review of literatures indicates that,the immunosuppressive mechanisms of cyclosporine A consist of:① the calcineurin/nuclear factor of activated T-cells pathway,②the activation of JNK and P38 signaling pathways,③other effects.CONCLUSION:Cyclosporine A selectively regulates the function of peripheral blood lymphocytes subgroup,blocks the activation of cytotoxic T-cells,and possibly inhibits the formation or reaction of memory T-cells.But it doesn't affect activation and proliferation of suppressive T-cells,or expression of interleukin-2 receptors,which may induce selective immunosuppression.

Surgical treatment is the only cure treatment for patients with inferior vena cava tumor thrombus in hepatic segment and upper hepatic segment.The accurate diagnosis of tumor thrombus is very important.In preoperative imaging examination,the abdominal enhanced CT scan and the inferior vena cava MRI scan were the best methods for the diagnosis and evaluation of the tumor thrombus in hepatic segment and upper hepatic segment.Compared with the tumor thrombus below the liver,the tumor thrombus in hepatic segment or above hepatic segment extend widely,and the operation are more difficult.For simple inferior vena cava tumor thrombus (the top of the thrombus has reached the level of hepatic vein),Retroperitoneal approach combined with transperitoneal approach should be used.Open surgery is the standard procedure for other tumor thrombus in hepatic segment and upper hepatic segment.In addition to exposure of inferior vena cava below the hepatic vein,the liver and the first hepatic hilum should be exposed.For tumor thrombus in the atrium,after the longitudinal incision of diaphragm,we use Milking technology to squeeze thrombus into inferior vena cava.Then we use catheterization technology to remove thrombus.For difficult atrial tumor thrombus,an extracorporeal circulation should be performed.The median incision in the chest should be performed to open the chest and open the pericardium and remove the tumor thrombus.Patients with tumor thrombus in hepatic segment or upper hepatic segment should be diagnosed as early as possible and they need actively treated by operation.

Objective To discuss the curative effect and the prognosis of patients with renal cell carcinoma after laparoscopic radical nephrectomy. Methods One hundred and twenty-seven cases of renal cell carcinoma treated with laparoscopic radical nephrectomy between October 2002 and Decem-ber 2006 were reviewed. The perioperative complications and postoperative renal function were recor-ded and analyzed. Post-operative 1-year and 3-year actuarial survival rates, disease-free survival rates and tumor-specific survival rates were caculated respectively with Kaplan-Meier analysis. Quality of life(QOL) was compared before and after surgery by Karnofsky Performance Status measuring scale. Results Among the 127 patients, 107 cases were followed up of mean 23 months (4-51 months). 1-year and 3-year actuarial survival rates, disease-free survival rates and tumor-specific survival rateswere 95.6%, 95.6%; 95.8%, 95.8% and 96.8%, 96.8%, respectively. 3-year actuarial survival rate, disease-free survival rate and tumor-specific survival rate were 97.1%,98.6%, 98.6% in pT1-2 tumors, and were 90.2%, 85.6%, 90.2%in pT3a, tumors. Disease-free survival rate and tumor-spe-cific survival rate had significant differences between patients in stage pT1-2 and patients in stagepTa3a.91.6% of the patients scored the post-operative QOL above 80 by Karnofsky Performance Sta-tus measuring scale. Conclusions Patients who underwent laparoscopic radical nephrectomy have high survival rate, low complication incidence and good QOL. Post-operative survival rate is correlated with pathologic stage.

443) ?mol/L) due to upper urinary calculous obstruction,urgently treated by pneumatic lithotripsy(EMS,Switzerland) under ureteroscopy,from August 2002 to April 2006 in this hospital.After stone fragmentation and removal,an indwelling double-J stent was placed into the ureter at the same time.Results The continuity of the ureter was restored after one session of lithotripsy in all the 9 cases(14 sides).The ureteral calculi were thoroughly removed on one session in 7 cases(12 sides).Few residual stones were found in the renal pelvis in 2 cases(2 sides),in one of which the stones were spontaneously expelled after oral medication,and in another,after extracorporeal shock wave lithotripsy(ESWL).No severe complications happened,such as ureteral avulsion,rupture,or perforation.Concentrations of serum creatine were decreased to normal levels within 3~7 days after operation in all the 9 cases.The gross blood urine disappeared in 1~4 days postoperatively.The patients were discharged from the hospital after 3~7 days (mean,5 days) after operation.The double-J catheter was removed at 1~2 months postoperatively.Follow-up examinations in 7 cases for 2~30 months(mean,14 months) found normal levels of serum creatine and no recurrent urinary stones under B-ultrasonography or X-ray radiography.Conclusions Ureteroscopic pneumatic lithotripsy in the treatment of acute renal failure due to upper urinary calculous obstruction is an effective treatment with short operation time,safety,and minimal trauma.By using this procedure,both sides of ureteral stones can be removed on one session.

Objective To evaluate the efficacy of retroperitoneal laparoscopic radical nephrectomy.Methods A total of 126 patients underwent retroperitoneal laparoscopic radical nephrectomy from November 2002 to June 2006.The operation was performed through 3 lumbar ports.The renal artery and veins were blocked with the Hem-o-lok and then severed;the ureter was severed near the iliac blood vessel.Results A conversion to open surgery was required in 2 patients because of bleeding and in 1 patient because of severe adhesion.The mean operation time was 115 min(range,60~255 min) and the mean blood loss was 112ml(range,20~1000 ml).Blood transfusion was required in 2 patients.Complications occurred in 7 patients(spermatic vein injury in 1 patient,accessory renal artery injury in 1 patient,inferior vena cava injury in 1 patient,hemorrhage of renal artery stump in 1 patient,renal vein injury in 2 patients,and pancreatic tail injury in 1 patient).The patient with inferior vena cava injury was followed for 2 years and no abnormal findings were found.The patient with pancreatic tail leakage was followed for 1 year and no pancreatitis or liquid in the renal fossa was detected.The remaining 5 patients with complications presented no abnormal findings.The mean postoperative hospital stay was 5 days(range,4~8 days).Pathological results included renal clear cell carcinoma in 117 patients,cystic renal cell carcinoma in 3 patients,renal pelvis transitional cell carcinoma in 2 patients,chromophobe carcinoma in 1 patient,hamartoma in 2 patients,and oxyphil cell tumor in 1 patient.One patient developed a liver metastasis 6 months after operation,and died 1 year after operation.The rest of 125 patients were followed for a mean of 27 months(range,1~43 months),and survived without renal fossa or incision metastasis,or distant recurrence.Conclusions Retroperitoneal laparoscopic radical nephrectomy is a safe,reliable,and effective technique for renal tumors.

Objective To evaluate the efficacy and safety of percutaneous nephrolithotomy under ultrasonic guidance for the treatment of renal calculi. Methods Percutaneous nephrolithotomy using pneumatic or holmium laser lithotripsy under ultrasonic guidance was performed in 26 patients from January 2005 to November 2006.Among them,46 patients had single stones and 27 had multiple renal calculi.Unilateral renal calculi were found in 67 patients and bilateral calculi in 6.Staghorn calculi were identified in 11 patients.Results Of the 73 patients,a successful stone removal on one session was achieved in 57 patients,a second-look stone removal was needed in 13 patients,and 3 patients underwent three times of operation.During the operation,a single tract was used in 53 patients,double tracts in 18 patients,and three tracts in 2.A mini-invasive tract(F14～F18) was used in 47 patients,and a standard tract(F24) was established in the remaining 26 patients.The operation time was 50～160 min(mean,86 min).The stone-free rate was 96.2%(68/73),and the residual stones in other 5 patients were all

Objective To explore the operative approach, method,indication,and clinical feasibility of laparoscopic or retroperitoneoscopic treatment of ploycystic kidney.Methods The renal cyst unroofing(bilateral,9 cases;unilateral,4 cases) was performed under laparoscope(2 cases) or retroperitoneoscope(11 cases).The renal adipose capsule was dissected with a harmonic scalpel to fully visualize the whole kidney.According to preoperative positioning results,the cysts at all sizes were exposed.Then all visible cysts were unroofed or fenestrated with a margin 0.5 cm from the renal parenchyma.The cystic fluid was drawn out as much as possible.Results The operations were completed smoothly in the 13 cases.Pneumatothorax developed on the day of laparoscopic operation in 1 case,and then was cured by closed thoracic drainage.The operation time was 50～240 min(mean,139 min),and the blood loss was 10～200 ml(mean,58 ml).Patients began out-of-bed activities in 1～2 days after operation and were discharged from hospital at 3～10 days.The pathological findings were in accordance with changes of ploycystic kidney.Follow-up examinations were carried out for 1～30 months(mean,14.3 months).Back pain was relived in 8 out of 11 cases.In 3 patients with a high blood pressure,the systolic pressure was decreased by 16～19 mm Hg at 9 months after operation.Ten patients presented normal hepatic and renal functions,while the remaining 3 patients with preoperative increased creatinine levels of 194～301 ?mol/L had a drop by 20～40 ?mol/L.Conclusions Treatment of cyst unroofing under laparoscope or retroperitoneoscope is a safe and effective method in the treatment of ploycystic kidney,being worthy of clinical recommendation.

Objective To summarize the complications of retroperitoneal laparoscopic nephrectomy.Methods From November 2002 to May 2006,122 patients with renal carcinoma underwent retroperitoneal laparoscopic nephrectomy.Complications occurred in 7 patients,and the morbidity was 5.7%.One case of injury to vena spermatica converted to open surgery,the blood loss was 1000 ml with blood transfusion 800 ml.One postoperation hemorrhage of accessory renal artery which was cut off only by harmonic scalpel,leading to blood pressure decrease to 90/60 mm Hg,and a reoperation was performed and the blood loss was 600 ml with blood transfusion 400 ml.Injury of inferior vena cava by linear cutter stapler in one case,and there was no blood loss.Hemorrhage of renal artery stump after linear cutter stapler in one case and it was controlled by titanium clip.Injury of renal vein occurred in two cases and all were controlled by Hem-o-lok or titanium clip.Injury of tail of pancreas in one case and a drainage tube was placed.Results A patient with vena cava injury was followed for 30 months and no abnormality was noted.A patient with pancreas injury was followed for 1 year and nothing remarkable was noted.The other 5 cases was followed for 20-40 months,and they remained in good health.Conclusion The major complication for retroperitoneal laparoscopic surgery is injury to large blood vessels,the principle of treatment is to elevate the pressure of pneumoperitoneum up to 18-20 mm Hg and clip the blutpunkte or convert to open surgery promptly.A good drainage is necessary for the treatment of injury of pancreas.

Objective To evaluate the safety and effectiveness of the Hem-o-lok in retroperitoneal laparoscopic nephrectomy.Methods A total of 178 patients underwent retroperitoneal laparoscopic nephrectomy from November 2003 to November 2006.The operation was performed through 3 lumbar ports.The renal artery and veins were blocked with the Hem-o-lok and then severed.The ureter was cut at the site near the iliac blood vessel.For living donor nephrectomy,the kidney was taken out and infused with 4℃ kidney preserving fluid immediately.Results The operation was successfully completed in all the 178 cases and there was no conversion to open surgery.No Hem-o-lok ligating clips became dislodged.The mean operation time was 100 min(60-200 min),and the mean blood loss was 95 ml(20-200 ml).Complications included renal vein injury in 1 patient and pancreatic tail injury in 1 patient.The mean length of postoperative hospital stay was 5 days(4-8 days).Pathological results showed renal clear cell carcinoma in 65 patients,renal cystadenocarcinoma in 3 patients,renal leiomyosarcoma in 1 patient,renal lymphoma in 1 patient,renal oncocytoma in 2 patients,renal hamartoma in 2 patients,ureteral transitional cell carcinoma in 12 patients,ureteral squamous cell carcinoma in 2 patients,renal pelvis transitional cell carcinoma in 31 patients,renal pelvis xanthogranuloma in 1 patient,renal tuberculosis in 4 patients,accessory kidney in 1 patient,renal calculus in 4 patients,nephrohydrosis in 4 patients,and renal abscess in 1 patient.A total of 136 patients were followed for 1-36 months(mean,25 months),involving 64 patients followed for

Objective To evaluate the curative effectiveness of ureteroscopic pneumatic lithotripsy in the treatment of ureteral lithiasis.Methods Ureteroscopic pneumatic lithotripsy was performed in 158 cases of ureteral calculi(163 sides)by using the Wolf F8/9.8 rigid ureteroscope and the EMS pneumatic ballistic lithotriptor from August 2002 to April 2006.The operation was carried out under intravertebral anesthesia.Under the irrigation with normal saline,the ureteroscope was advanced into the ureter.Then the ureteral stones were fragmented by pneumatic lithotripsy and removed.Afterwards,a further exploration of the ureter above the lesion was conducted and a double-J drainage tube was placed.Results The operation time was 15-90 min(mean,40 min).The total successful fragmentation rate was 96.9%(158/163),involving a success rate of 86.6%(13/15)for upper stones,96.9%(46/49)for middle stones,and 100%(99/99)for lower stones.The stone migration into the renal pelvis was encountered in 2 cases of upper ureteral calculi(treated by extracorporeal shock wave lithotripsy following a double-J tube placement)and in 3 cases after stone fragmentation(treated by stone expulsion with drugs or extracorporeal shock wave lithotripsy following a double-J tube placement).Ureteral perforation happened during the procedure in 3 cases(1.8%),requiring a double-J tube placement.No serious complications occurred,such as ureteral mucous avulsion or rupture and injuries of neighboring organs or vessels.No conversion to open surgery was required.Follow-up checkups for 1-38 months in 125 cases with B-ultrasonography or KUB film found no recurrence.Conclusions Ureteroscopic pneumatic lithotripsy is a safe,effective,and feasible technique for ureteral lithiasis.