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.

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 evaluate the outcomes of laparoscopic live donor nephrectomy via retroperitoneal approach. Methods From December 2003 to June 2004,6 patients underwent laparoscopic live donor nephrectomy (younger brother to elder sister in 1 case,elder brother to younger brother in 1, younger sister to elder brother in 1,elder sister to younger brother in 1,father to son in 1,mother to son in 1).For tissue matching,1 case was mismatched of 0 locus,2,of 2 loci and 3,of 3 loci.The results of PRA and lymphocytotoxicity test were negative.The patient was placed in the lateral decubitus.With 3 trocars, the left kidney was dissected via retroperitoneal approach.The arteries and veins were cut off by endoscopic articulating linear cutter. The donor's left kidney was taken out through a 6-7 cm long incision between 2 trocars.Staplers on renal arteries and veins were cut off,and the donor kidney was perfused with liquid,and then was implanted at the right iliac fossa of the recipients.Triple immunosuppressant therapy was used to prevent rejection. Results Laparoscopic donor nephrectomy was successfully performed on all the 6 cases by retroperitoneal approach.The kidney transplantations using the donor live kidneys were also successful.Postoperatively,the mean urine volume was 5036 ml(range,3500-6500 ml) on the first day;the mean serum creatinine level was 598 ?mol/L on the first day and 129 ?mol/L at 1 month.Follow-up of 3-9 months showed that the renal function was normal and no rejection occurred. Conclusions Laparoscopic donor nephrectomy via retroperitoneal approach is safe,feasible,and less invasive to the donor; however,this technique needs skilled surgeons of laparoscopy and renal transplantation.

Objective To evaluate the safety and efficacy of retroperitoneoscopic radical nephrectomy. Methods A total of 46 patients (24 males and 22 females;age range,23-86 years;mean age,58 years) underwent retroperitoneoscopic radical nephrectomy from November 2002 to July 2004.Of the 46 cases,43 were detected by B-ultrasound during physical examination and the rest 3,when visiting doctors due to painless hematuria.The masses by B-ultrasound was on average 4.5 cm (range,1.5-8.0 cm) in diameter, with 17 masses at the upper pole of the kidney,13 at the middle and 16 at the inferior pole.CT scan was performed on all the 46 cases and MRI,on 41.The tumor size detected by CT and MRI was consistent with that by B-ultrasound.Preoperatively,3 cases had the tumors of clinical stage T 1N 0M 0,38 of T 2N 0M 0 and 5 of T 3aN 0M 0. Results The operative time was 60-255 min (mean,145 min),and blood loss was 20-1000 ml (mean,133 ml).Adrenalectomy was performed on 32 patients (70%).Complications occurred in 3 cases,of whom only 1 required conversion to open surgery due to injury of genital gland vein,with blood loss of 1000 ml.Pathology showed that 41 cases were of renal clear cell carcinoma,2 of cystic renal cell carcinoma,1 of chromophobe carcinoma,1 of hamartoma and 1 of oxyphil cell tumor.During the follow-up of 1-20 months (mean,9 months),45 patients survived;only 1 died of liver metastasis. Conclusions Retroperitoneoscopy radical nephrectomy is safe and effective.

Objective To evaluate the technique and effect of laparoscopic live donor nephrectomy via retroperitoneal approach. Methods Thirty-two donors (15 males and 17 females) underwent laparoscopic donor nephrectomy at our institution. Twenty-nine left and 3 right procedures were performed. Under general anesthesia, all donors were placed in lateral decubitus. Three transretroperitoneal trocars were used through different ports. The first 12 mm port was placed 2 cm inferior to the edge of rib and 1 cm lateral to the edge of sarcospinous muscle. The second 10 mm port was about 8 to 10 cm anterior to the first, or on the anterior axillary line and 2 cm inferior to the edge of rib. The third 5 mm port was also on the anterior axillary line but 2 cm superior to the iliac crest. The surgeon created the retroperitoneal working space with a constructed catheter balloon device, and made the donor kidney and ureter dissociated. Renal arteries and veins were cut with endoscopic articulating linear stapler for the first 6 patients and then with Hemo-Lok, a plastic clip with a lock, for the others. Finally, the dissected donor kidney and ureter were taken out through an incision extended from the first trocar port. Results All the 32 donor grafts were dissected successfully. The duration of procedure was ranged from 60 to 180 min, and the volume of blood loss was from 20 to 200 ml. The range of warm ischemia time was 3 to 8 min, and 25 to 50 min of cold ischemia time. Short renal veins were found in 3 cases, 1 cm, 1.5 cm and 2 cm respectively. And one case of renal endoarterial injury occurred. On the day after transplantation, the urine volume of recipients was from 2800 to 10 100 ml. There was no delayed graft function found in recipients. Conclusion Laparoscopic donor nephrectomy via retroperitoneal approach is available and safe to renal transplantation with minimal invasion to donors. It can help to obtain donor grafts with higher quality, though skillful laparoscopic technique is demanded.

1cm.

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.

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 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.