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.

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.

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 evaluate the efficacy and safety of percutaneous nephroscopic lithotripsy for the treatment of bilateral upper urinary calculi. Methods From July 2004 to December 2008,we performed percutaneous nephroscopic lithotripsy under X-ray or ultrasonic guidance for 35 patients with bilateral upper urinary calculi. Of the 35 patients,bilateral renal calculi were found in 18 patients,unilateral renal and unilateral ureteral calculus in 10,bilateral ureteral calculi in 7. Results In 35 patients (70 sides),the calculi was removed through a single tract in 49 sides,through double tracts in 18 sides,and through triple tracts in 3 sides. The mean operation time for unilateral PCNL was 66 min (ranged from 20 to 185 min). The stone-free rate was 80% (56/70) on one session. A second-look stone removal was needed in 8 laterals,and 3 laterals underwent three times of lithotomy. In three sides,a few residual renal stones were found after the first operation,but no second operation was performed. The final stone-free rate was 91.4% (64/70) in all of the cases,among which the stone-free rate was 100% (24/24) for ureteral stones and was 87% (40/46) for renal stones. In this series,no chest or abdominal injuries,intestinal perforation,or injuries to surrounding organs were detected. The patients were discharged from hospital in 5 to 30 days,and then were followed up for 3 to 6 months. During the follow-up,B-ultrasonography and KUB+IVP found no recurrence of calculi. Conclusions Percutaneous nephrolithotomy is effective and safe for bilateral upper urinary calculi. By skilled urologists in conditioned hospital,simultaneous bilateral percutaneous nephrolithotomy performed on bilateral upper urinary calculi can shorten the cycle time of treatment and hospitalization.

Objective To explore the techniques and efficacy of retroperitoneal laparoscopic operations in the treatment of renal cyst. Methods A total of 35 patients were operated on under general anesthesia. A water-filled balloon was used to dilate the retroperitoneal cavity. The renal cyst was exposed by identifying the psoas major muscle, peritoneal reflection, pillar of diaphragm and so on. All cyst walls were unroofed with ultrasonic scalpel 3～5 mm from the edge of renal parenchyma. Results With renal cysts removed, the operations were successfully accomplished in all the 35 patients. The operation time was 15～60 min (mean, 32 min). The intraoperative blood loss was 5～60 ml (mean, 35 ml). The postoperative hospital stay was 3～6 days. Pathological examinations reported benign lesions in 34 patients and suspected cystadenocarcinoma in 1 patient. All the 35 patients were followed for 1～22 months. No recurrence was found with exception of 1 case of remaining renal cyst 1.5 cm in diameter under B-ultrasonography at the first postoperative month. The patient with suspected adenocarcinoma had been followed for 1 year and no evidences of neoplasm or metastasis were detected on the chest roentgenogram and B-ultrasonography of the liver and the kidneys. Conclusions Retroperitoneal laparoscopic unroofing is a safe and effective procedure for renal cyst.

Objective To evaluate the feasibility and curative effects of retroperitoneal laparoscopic surgery for adrenal pheochromocytoma. Methods Clinical records of 9 cases of retroperitoneal laparoscopic adrenalectomy of pheochromocytoma from October 2002 to November 2004 were reviewed. Results The operations were successfully completed in all 9 cases without severe complications. A sudden rise of blood pressure with an amplitude over 30 mmHg appeared in 3 cases during the operation, which took a favorable turn after adjusting the surgical performance and blocking the central vein. The operation time was 90~210 min (mean, 150 min). The intraoperative blood loss was 30~150 ml (mean, 50 ml). Blood transfusion was required in no cases. The postoperative length of hospitalization was 4~9 days (mean, 5 days). Pathological examination revealed benign adrenal pheochromocytoma in all cases. Follow-up for 3~24 months (mean,11 months)in the 9 cases found symptom free and no recurrence by B-ultrasonography or CT scans. Conclusions Retroperitoneal laparoscopic surgery for adrenal pheochromocytoma is a feasible procedure which offers advantages of minimal invasion, short operation time, less blood loss, quick postoperative recovery, fewer complications and good curative effects, having a promising future.

Objective To investigate a new method of pneumatic ballistic lithotripsy for the treatment of bladder calculi. Methods A ureteroscope or nephroscope was inserted into the bladder via outer sheath of resectoscope. Then pneumatic ballistic lithotripsy was performed under endoscope to fragment and remove bladder stones. Results Stones were thoroughly removed from the bladder on one session in all 20 patients. No major haemorrhage, perforation of the bladder, or water intoxication happened intraoperatively or postoperatively. Follow-up for 2~18 months (mean, 4 6 months) in the 20 patients showed no recurrence of calculi under B-ultrasonography or symptoms of urethral stricture like dribble urination. Conclusions Pneumatic ballistic lithotripsy via outer sheath of resectoscope is effective in the treatment of bladder calculi.

Objective To discuss anatomic landmarks during retroperitoneoscopic radical nephrectomy. Methods A total of 46 patients underwent retroperitoneoscopic radical nephrectomies from November 2002 to July 2004.The first trocar was introduced at the union of the site 2 cm below the 12 th costal margin with the lateral side of the musculus sacrospinalis.The second trocar was placed at the midpoint of the upper border of the iliac crest,or at the location above and medial to the anterior superior iliac spine.And the third one was inserted at the union of the anterior axillary line with the costal margin.In the first place,the greater psoas muscle was identified as the dorsal marker.Then the diaphragmatic muscle was identified as the posterior marker of the upper pole of the kidney,and the adrenal gland as the medial marker of the upper pole of the kidney,and the peritoneum as the ventral marker.The renal vein lay below and anterior to the renal artery.The right renal vein was routinely sperated right up to the joining site with the inferior vena cava.A linear cutter was used to resect the renal vein and artery respectively. Results The mean operation time was 145 min (range, 60~ 255 min) and the mean intraoperative blood loss was 133 ml (range, 20~1 000 ml). Adrenalectomy was performed in 32 patients (69 6%). A conversion to open surgery was required in 1 patient because anatomic landmarks could not be well seen. The inferior vena cava was wrongly closed off by 1/2 cross-section when using a linear cutter to sever the right renal vein in 1 patient. Peritoneal injuries happened in 4 patients.Follow-up was carried out for 1~20 months (mean,9 months) in all the 46 patients.One patient died of liver metastasis 1 year after the surgery, while the remaining 45 patients survived without recurrence. Conclusions Proper identification of anatomic landmarks is crucial to a successful retroperitoneoscopic nephrectomy.

Objective To introduce the experience for managing the renal artery and vein during retroperitoneal laparoscopic nephrectomy. Methods A series of 52 consecutive patients underwent retroperitoneal laparoscopic nephrectomy. The operation was performed under a general anesthesia. Patients were maintained in the lateral decubitus position. Two 10 mm trocars and one 5 mm trocar were introduced into the lumbar part. A self-made water-filled balloon was used to dilate the retroperitoneal cavity. In the performance of dissection of the renal artery, the renal hilum should be kept away from as much as possible. When the artery had been separated for 1~2 cm in length, a linear cutter was utilized to sever it. The management of the renal vein was identical with that for the artery. During the management of the renal artery and vein, utmost care should be exercised to dissect the vessels longitudinally; else they were liable to be ruptured. Results All procedures were completed smoothly. A double artery supply was found in 6 patients and a triple artery supply in 1. Five patients had a double venous return-flow. A conversion to open surgery was required in 1 patient for spermatic vein injuries. No postoperative vascular complications were observed. Conclusions Use of a linear cutter to sever the renal artery and vein under retroperitoneal laparoscope is safe and reliable.

Objective To summarize the clinical experience of retroperitoneoscopic surgery in the treatment of adrenal tumors. Methods Retroperitoneoscopic resection of adrenal tumors was performed in 35 patients(12 males and 23 females) aged 25~72 years(mean,49.8 years).The tumor was left-sided in 15 patient and right-sided in 20 patients.There were 5 cases of pheochromocytoma,10 cases of primary hyperaldosteronism,2 cases of Cushing's disease,2 cases of paraganglioma,and 16 cases of dysfunctional adenoma.The operation was performed through 3 lumbar ports.A self-made water-filled balloon dilator was employed to expand the retroperitoneal cavity,and then the tumor was removed by using a harmonic scalpel.Results The procedure was successfully completed in all the 35 patients,with no need of conversions to open surgery.The intraoperative blood loss was 10~500 ml(mean,74 ml).No blood transfusion was required.The operation time was 45~200 min(mean,90 min).Conclusions Retroperitoneoscopic adrenalectomy has advantages of satisfactory effects,short operation time,little blood loss and invasion,and quick recovery.It can replace most of traditional open operations for adrenal tumors.