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 evaluate the clinical efficacy of retroperitoneoscopic nephrectomy for tuberculous nonfunctioning kidneys.Methods From October 2003 to November 2006,retroperitoneoscopic nephrectomy was performed in nine cases of tuberculous nonfunctioning kidneys in our hospital.Dissecting kidney and ureter with ultrasound scalpel,blocking kidney pedicle with Endo-GIA(n=4) or Hem-o-lok(n=5),kidney was put into kidney bags and taken out.Results All nine cases were performed nephrectomy successfully without conversions to open surgery.The mean of operative time was 110 min(range,90-180 min);the mean of blood loss was 94.4 ml(range,20-200 ml);the mean of postoperative hospital stay was 5.5 days(range,3-8 days).One case had a little cheese-like pura extravasation induced by laceration of kidney capsule.Peritoneum damage occurred in one case.The nine patients showed a primary healing of the wound.Follow-up of 1-38 months in nine cases showed normal function of contralateral kidney.Conclusions Retroperitoneoscopic nephrectomy for renal tuberculosis has advantages of minimal invasion,less blood loss and quicker recovery,therefore it is a fairly safe and reliable procedure for tuberculous nonfunctioning kidneys.

Objective To evaluate the clinical efficacy of retroperitoneoscopic surgery for adrenal cyst.Methods From May 2002 to December 2006,retroperitoneoscopic surgery was performed in 12 cases of adrenal cyst.The diameter of cyst was ranged from 3.6 cm?2.2 cm-10.0 cm?8.0 cm.After the retroperitoneal space was dilated,the perinephric fascia was opened.The adipose tissues around the upper polar of the kidney and the adrenal gland were dissected.Then the upper polar of the kidney and the cyst of adrenal gland were separated along the renal surface with a ultrasound scalpel.The cysts and normal adrenal tissue 1 cm away from the cysts were resected.Results The operation was successful in all of 12 patients without conversion to open surgery.The mean operative time was 65 min(range,50-120 min);the mean blood loss was 45 ml(range,10-150 ml);the mean hospital stay was 4.5 days(range,3-7 days).Intraoperative cyst rupture occurred in 2 cases of larger cysts,then the cystic fluid was drawn out and the cyst wall was fully excised.No incision infections occurred.A follow-up period of 2-55 months(mean,32 months) in 12 patients showed no cysts recurrence.Conclusions Retroperitoneoscopic surgery for adrenal cyst has the advantages of minimal invasion,less blood loss,quicker recovery,and shorter hospital stay,therefore it provides the first choice for adrenal cyst.

Objective To evaluate the clinical efficacy of permanent 125I prostate brachytherapy monotherapy in patients with early prostate cancer. Methods A total of 18 patients with prostate cancer was diagnosed by prostate biopsy,with Gleason score 5 - 6,average PSA 5.09 ng/ml (range,0.38 -8.73 ),and clinical stage T1c - T2a.All patients underwent 3-dimensional conformal brachytherapy with transperineal ultrasound-guide 125I seeds prostate implantation. Results None of the patients had any adverse events during the operation processes.The operation time was from 37 to 52 minutes and postoperative hospitalization time was from 3 to 4 days.The mean number of implanted 125I seeds was 54.All patients were followed up for 3 to 57 months with a mean of 15 months,while one patient was lost during followingup.The survival rate of PSA progression free was 100％ (17/17).The PSA was under 0.2 ng/ml for a long time in the 7 cases who had been followed-up for more than 18 months.The PSA did not show any rising trend in all 17 cases.No severe complications occurred in all cases. Conclusions Brachytherapy monotherapy with 125I seeds implantation is safe and effective for patients with early prostate cancer.

Objective To evaluate the recovery rate of erectile function (EF) and identify various factors predicting the recovery of EF in men undergoing laparoscopic radical prostatectomy (LRP) in our center.Methods From January 2011 to December 2012,a total of 106 men with localized prostate cancer underwent LRP in our center by one surgeon were included,and we gathered the preoperative EF condition and perioperative factors,such as patients' age,comorbidity and surgical procedure,et al.We followed up all the patients by telephone in August 2013 to collect the EF recovery data of these paticnts after LRP,with the mean follow-up of 18 (8-31) months.We analyzed the perioperative factors in order to predict the EF recovery after LRP.Results A total of 60 patients with preoperative sexual activity were included,and there was no difference in baseline data compared with other cases.Recovery of potency was defined as postoperative penile erection.The recovery rate of EF was 46.7％ (28/60) without the use of any drugs or devices for erection assistance.In our study,the recovery rate of EF in age ≤60 years was 90.0％ (9/10),and it was better than other two older groups (P =0.001).In patients whose preoperative IIEF-5 score was 22-25,the recovery rate of EF was 66.7％ (8/12),and it was better than those with IIEF-5＜22 (P=0.006).The recovery rate of EF in patients with preserved neurovascular bundle was 53.1％ (26/49) and it was 83.3％ (5/6) in patients with preserved accessory pudendal artery,which was better than those without preservation (P=0.036 and P =0.023).Conclusions In our study,age and preoperative EF were the significant factors to predict potency recovery,and preservation of neurovascular bundle and accessory pudendal artery during LRP were the positive predictor factors.

ObjectiveTo compare the clinical characteristic and postoperative histopathological parameters in different prostate size and to assess the effect of prostate volume on histopathological outcomes in patients after laparoscopic radical prostatectomy. MethodsTwo hundred and sixteen patients from 2006 to 2011 who were proved prostatic carcinoma by biopsy and performed laparoscopic radical prostatectomy wewe retrospectively evaluated.All patients were divided into the small group ( ＜ 30 ml,103 cases),intermediate group(30 -60 ml,71 cases) and large group ( ＞60 ml,42 cases) according to prostate volume.Clinical variables included age,body mass index (BMI),preoperative PSA level,prostate volume,percentage of positive needles,clinical stage,and biopsy Gleason score (GS).Histopathological parameters included pathological GS,upgrading or not compared to biopsy GS,pathological stage and surgical margins status.Preoperative clinical variables and postoperative histopatholgogical parameters were compared among the 3 prostate groups. ResultsPatients with smaller prostates had lower PSA levels than those with intermediate and larger prostates (P =0.000).They also had worse histopathological outcomes such as pathological GS ( P =0.034 ),upgrading of GS ( P =0.037 ),and pathological stage ( P =0.025 ).35.0％ of patients in smaller prostate group had a positive surgical margin compare to 33.8％ and 19.0％ in intermediate and larger prostate groups,but there was no significant difference (P =0.152).ConclusionMen with smaller prostate may have more high-grade cancer and more advanced disease after laparoscopic radical prostatectomy.

Objective　To evaluate the safety and primary outcomes of transumbilical laparoendoscopic single-site radical nephrectomy (LESS-RN) by using home-made single-port device.　Methods From July 2010 to November 2011,we had performed transumbilical LESS-RN on eleven renal cell carcinoma patients by using the home-made single-port device.There were 5 males and 6 females in this group.The mean age was 49 (37 -68) years and mean body mass index was 24.2 (18.4 -30.4) kg/m2.Ultrasound and CT scan revealed 11 renal tumors (7 on left and 4 on right),with 3 on the upper pole,4 in the middle and 4 in the lower pole.There were 2 cases with suspicious lymph node metastasis and one case with renal cyst.There was no distant metastasis.The intracorporal procedure was similar to conventional laparoscopic radical nephrectomy.　Results　Except two cases converted to conventional laparoscopic RN and one case converted to hand-assisted laparoscopic RN,the other procedures were completed successfully without open conversion.The mean operative time was 225 min (155 -297 min) and mean estimated blood loss was 271 ml (50 -900 ml).Postoperative results showed that all cases were renal cell carcinoma and there were 3 cases in T1a,5 cases in T1b and 3 cases in T2a.The mean visual analog pain scale (VAPS) was 4 (3 -6),and mean hospital stay was 10 d (5 -15 d).With the mean follow-up of 17 months (8 -24 months),all patients were alive with no evidence of local recurrence or metastasis.Patients were satisfied with the cosmetic results of the wound recovery.　Conclusions　Transumbilical LESS-RN using home-made single-port device is a safe approach in selected patients and has excellent cosmetic results. Primary oncologic outcomes are good.However,we will still need large clinic trials to further evaluate the efficacy and safety of LESSRN.

Objective A kidney transplantation patient who was diagnosed with autoimmune hemolytic anemia (AIHA) caused by passenger lymphocyte syndrome (PLS) was reviewed.Method A male kidney transplantation patient aged 31 was admitted due to severe anemia.Direct antiglobulin test (DAT) was positive and reticulocyte was elevated significantly,and PLS was diagnosed.He was treated with blood transfusion,glucocorticoid and intravenous immunoglobulin,and recovered at last.Result PLS is a rare but important cause of AIHA after kidney transplantation,often occurs in blood type A patient who received a kidney from a blood type O donor.Final diagnosis depends on the detection of anti-erythrocyte antibody in recipient serum.Conclusion PLS should be considered when anemia with unknown reasons occurred in kidney transplantation patients.

Objective To investigate the efficacy of plasmapheresis therapy for treating the antibody-mediated acute rejection (AMR) after kidney transplantation.Methods The study group consists of 2 male patients and 3 female patients,who suffered with AMR after receiving first-time allograft renal transplantation from January 2011 to September 2013 in our hospital.The age ranged from 41 to 52 years old,average 46 years old.The preoperative diagnosis in all patients was chronic renal insufficiency (uremia stage) and the regular hemodialysis was given to them.The 5 patients received basic immunosuppressive therapy,including cyclosporine A [5 mg/(kg · d)] or FKS06 [0.1 mg/(kg · d)],mycophenolate mofetil (MMF) (1.5 g/d) and steroids.All the antibody-mediated acute rejections were diagnosed by renal allograft biopsy and serum DSA determination within 2 weeks after transplantation.Seven cycles of plasmapheresis rescue therapy were given to those patients respectively after the failure therapy of high dose of corticosteroids (1 000 mg/d) and ALG (250 mg/d).4 cases with primary glomerulonephritis,whose preoperative serum creatinine level was (784± 154) μ mol/L,were given plasmapheresis therapy within 2 weeks after transplantation.One case with primary anti-glomerular basement membrane disease,whose preoperative serum creatinine level was 935 μmol/L,received plasmapheresis 35 d after transplantation.The serum DSA in all patients was positive before plasmapheresis.Results After 7 cycles of plasmapheresis rescue therapy,the AMR was reversed in four 4 cases,whose plasmapheresis was given within 2 weeks after transplantation.Within three months follow-up,their renal function recovered well,which the mean serum creatinine level was (113± 12) μmol/L.In the case,whose plasmapheresis was given 35 days after transplantation,rejection was not reversed.His serum creatinine was 524 μmol/L and the intermittent hemodialysis was given,subsequently.With a follow-up of 12 months,the ultrasound examination showed that the atrophy of transplanted kidney and a high level of serum creatinine (758 μmol/L).Low dose of FK506 (0.5 mg/d) was given based on those results.Conclusions Active application of plasmapheresis can effectively reverse antibodymediated acute rejection within two weeks after transplantation.

Objective To assess the impact of learning curve on perioperative complications in laparoscopic radical prostatectomy (LRP) by a series of consecutive 200 cases in a single center.Methods Two hundred patients who were biopsy proved prostatic carcinoma and underwent LRP were retrospectively evaluated.All the operations were performed by professor Ma Lulin.The patients were divided into 4 groups according the time of operation.All the clinical data,including age,body mass index (BMI),preoperative PSA level,biopsy Gleason score,and clinical stage were collected.Operative parameters and peri-operative complications were evaluated,including operative time,blood loss,transfusion rate,and perioperative complications.The complications were evaluated by Clavien classification system.Results Age,BMI,PSA,prostate volume,biopsy Gleason score and clinical stage had no significant difference among the 4 groups (P ＞ 0.05).The operative time was gradually lowered from group one to group four.Significantly less blood loss occurred after every 50 cases of LRP (P ＜ 0.001).The complication rates were 15.5％ in this series,28.0％,18.0％,12.0％ and 4.0％ for group one to group four respectively.The complication rate reduced as experience was gained (P =0.008).The rates of mild complications were 24.0％,14.0％,6.0％ and 4.0％,and severe complication rates were 4.0％,4.0％,6.0％ and 0,respectively.Conclusion With experience was gained and technique was improved,the operative time and blood loss of LRP decreased and complication rate reduced substantially.