Laparoscopic live donor nephrectomy

Live donor renal transplantation has many advantages including greater graft and patient survival, shorter waiting periods, improved human leukocyte antigen matching, and less cold ischemia. Until recently, disincentives from the operation, such as prolonged hospitalization, postoperative pain, and significant convalescence, have deterred live donor renal transplantation. This article describes the technique of laparoscopic live donor nephrectomy and briefly reports the results. The procedure has resulted in improved postoperative recovery and shorter convalescence, with no effect on recipient renal function.     

Laparoscopic live donor nephrectomy: outcomes equivalent to open surgery

A shortage of kidney donors has contributed to the interest in laparoscopic live-donor nephrectomy. Three transperitoneal ports are used, as is an AESOP robot. To maintain urine flow, the donor is kept volume expanded during the procedure, and the pneumoperitoneum pressure is minimized. The most critical and hazardous part of the surgery is dissection of the renal artery and vein. Abundant periureteral tissue should be left to protect the blood supply. Harvest of the right kidney is more difficult. Placing the extraction incision in the right upper quadrant and using a Satinsky clamp instead of a stapling device at the origin of the renal vein will provide maximum venous length and help prevent postoperative thrombosis of the allograft. In the first 175 laparoscopic renal harvest procedures at Johns Hopkins, the complication rate was 14%, the rate of open conversion was 2%, and 3% of the patients required transfusions. These rates improved with experience. There was no significant difference in the performance of the allografts or the recovery of the recipients from what is seen after open kidney harvest. Wider acceptance of laparoscopic renal harvest will increase the number of donors and will be helped by development of methods and devices that shorten the learning curve.     

Laparoscopic management of urachal cysts in adulthood

PURPOSE: Managing persistent and symptomatic urachal anomalies requires wide surgical excision. Such intervention is recommended to prevent symptom recurrence and complications, most notably malignant degeneration. However, traditional open excision is associated with significant morbidity and prolonged convalescence. We report our experience with the laparoscopic excision of urachal remnants as a less morbid, minimally invasive surgical alternative. MATERIALS AND METHODS: Between October 1993 and December 1999, 4 patients with a mean age of 43.3 years who had a symptomatic urachal cyst underwent laparoscopic radical excision of the urachal remnant. Using 2, 10 mm. and 1 or 2, 5 mm. ports the urachus and medial umbilical ligaments were divided at the umbilicus cephalad to the cyst. The specimen, which included the urachus, cyst and medial umbilical ligaments, was then separated from the bladder dome with or without the bladder cuff and removed intact. We reviewed the perioperative records to assess morbidity, recovery and outcome. RESULTS: All 4 procedures were completed successfully. No intraoperative or postoperative complications were reported at a mean followup of 15 months (range 2 to 24). Mean operative time was 180 minutes (range 150 to 210) and average hospital stay was 2.75 days (range 1 to 4). Pathological evaluation confirmed a benign urachal remnant in each case. All patients resumed normal activity within 2 weeks. CONCLUSIONS: To minimize the morbidity of radical excision the laparoscopic management of benign urachal remnants in adulthood is efficacious and our preferred method of management.     

Modeling the cost of management options for stage I nonseminomatous germ cell tumors: a decision tree analysis.

PURPOSE: Patients with clinical stage I nonseminomatous germ cell tumors (NSGCTs) have been managed with surveillance, chemotherapy, or retroperitoneal lymphadenectomy (RPLND) with similar survival outcomes. Cost factors influencing the choice of therapy were evaluated using computer-based decision analysis. METHODS: A detailed model was developed that integrates projected costs for more than 60 possible treatment outcomes. It incorporates primary, adjuvant, and salvage chemotherapy, primary and post-chemotherapy RPLND, and both laparoscopic and open surgical approaches. Starting values and probabilities were derived from a comprehensive meta-analysis of the last 25 years of testes cancer literature. Hypothesis testing was performed using sensitivity analysis. RESULTS: The model predicts a cost premium for both primary chemotherapy (18.7%) and RPLND (51.7%) compared with surveillance. If laparoscopic RPLND was practiced, the cost premium for primary surgery (29.1%) approached that of chemotherapy (26.4%). Open RPLND was 1.25x as costly as laparoscopic RPLND, primarily because of longer hospitalization. The choice of open RPLND yielded a 6.9% cost premium for a surveillance program in this model. For such a program, primary chemotherapy became cost advantageous when the probability of recurrence during surveillance was more than 46%. CONCLUSION: This model allows a variety of treatment cost hypotheses to be tested. Primary RPLND is never cost advantageous over surveillance or primary chemotherapy. Surgical costs can significantly increase the overall cost of a surveillance program. In stage I patients with high-risk tumor characteristics, primary chemotherapy may have a cost advantage over surveillance.     

Oxidative metabolism of the human eosinophil

We have compared the oxidative metabolism of human eosinophils (80%-90% purity) to that of neutrophils. Hexose monophosphate (HMP) shunt activity of eosinophils was higher than that of neutrophils under either resting or phagocytizing conditions. Eosinophil HMP shunt activity also was stimulated by phorbol myristate acetate, a membrane- active agent. Eosinophils showed a marked incorporation of 125I into trichloroacetic acid-insoluble material under resting conditions, which increased markedly during phagocytosis. Eosinophils likewise showed a greater reduction of nitroblue tetrazolium dye during phagocytosis than did neutrophils. Measurement of other parameters of oxidative metabolism indicated that eosinophils generated superoxide anion following phagocytosis and also elicited a burst of chemiluminescence similar to that observed during phagocytosis by neutrophils. Measurement of NADPH oxidase activity demonstrated that this enzyme was 3-6 times more active in fractions isolated from eosinophils than in corresponding fractions isolated from neutrophils; this was observed over a range of substrate concentrations. The eosinophil enzyme sedimented differently than the neutrophil enzyme with differential centrifugation; neither showed sedimentation characteristics of peroxidase. These data indicate that eosinophils possess a similar, although in some ways more potent, oxidative burst than neutrophils and are consistent with a role for NADPH oxidase in the initiation of that burst.     

Absence of IFNγ expression induces neuronal degeneration in the spinal cord of adult mice

Background  

Interferon gamma (IFNγ) is a pro-inflammatory cytokine, which may be up-regulated after trauma to the peripheral or central nervous system. Such changes include reactive gliosis and synaptic plasticity that are considered important responses to the proper regenerative response after injury. Also, IFNγ is involved in the upregulation of the major histocompatibility complex class I (MHC class I), which has recently been shown to play an important role in the synaptic plasticity process following axotomy. There is also evidence that IFNγ may interfere in the differentiation and survival of neuronal cells. However, little is known about the effects of IFNγ absence on spinal cord neurons after injury.