Reliability of laparoscopic skills assessment on video: 8-year results of the endoscopic surgical skill qualification system in Japan.

BACKGROUND AND PURPOSE: The Japanese Urological Association and Japanese Society of Endourology established a urologic laparoscopic skills qualification system called the Endoscopic Surgical Skill Qualification (ESSQ) System in Urological Laparoscopy in 2004. The reliability of video assessments by referees was evaluated. MATERIALS AND METHODS: Videos of nephrectomies or adrenalectomies performed by the applicants were assessed by two referees selected among a pool of 42 referees. From 2004 to 2011, 1308 urologists applied and 60.2% were qualified after video assessments. The results of skills assessments on 1220 videos that had fixed points by two referees were analyzed statistically. RESULTS: The average number of videos that each referee assessed was 58.1, with a range of 16 to 87. The accordance rate of the results of the video assessment, pass or fail, by the two referees was 68.9%. The scores of the video assessment by each referee averaged 62.7±2.4 (standard deviation) (full score was set at 75 points and ≥60 points was needed to pass). There was a statistically significant difference in the average video assessment score among the referees (P<0.001), and five referees showed significantly higher or lower average scores than the other referees. The percentage qualification of the final decision made by the Referee Committee on the videos originally assessed by each referee showed no significant differences among the 42 referees. The accordance rate of the results from the video assessment by each referee with the final decision by the committee showed a statistically significant positive correlation with the number of videos assessed by each referee (r=0.404, P=0.0080). CONCLUSIONS: The ESSQ system showed moderate reliability for the video assessments by the referees. It was concluded that the video assessments by the referees were fair for all applicants, because the final qualification rates showed no significant differences among the referees.

Positive correlation between motion analysis data on the LapMentor virtual reality laparoscopic surgical simulator and the results from videotape assessment of real laparoscopic surgeries.

PURPOSE: We studied the construct validity of the LapMentor, a virtual reality laparoscopic surgical simulator, and the correlation between the data collected on the LapMentor and the results of video assessment of real laparoscopic surgeries. MATERIALS AND METHODS: Ninety-two urologists were tested on basic skill tasks No. 3 (SK3) to No. 8 (SK8) on the LapMentor. They were divided into three groups: Group A (n=25) had no experience with laparoscopic surgeries as a chief surgeon; group B (n=33) had <35 experiences; and group C (n=34) had ≥35 experiences. Group scores on the accuracy, efficacy, and time of the tasks were compared. Forty physicians with ≥20 experiences supplied unedited videotapes showing a laparoscopic nephrectomy or an adrenalectomy in its entirety, and the videos were assessed in a blinded fashion by expert referees. Correlations between the videotape score (VS) and the performances on the LapMentor were analyzed. RESULTS: Group C showed significantly better outcomes than group A in the accuracy (SK5) (P=0.013), efficacy (SK8) (P=0.014), or speed (SKs 3 and 8) (P=0.009 and P=0.002, respectively) of the performances of LapMentor. Group B showed significantly better outcomes than group A in the speed and efficacy of the performances in SK8 (P=0.011 and P=0.029, respectively). Analyses of motion analysis data of LapMentor demonstrated that smooth and ideal movement of instruments is more important than speed of the movement of instruments to achieve accurate performances in each task. Multiple linear regression analysis indicated that the average score of the accuracy in SK4, 5, and 8 had significant positive correlation with VS (P=0.01). CONCLUSIONS: This study demonstrated the construct and predictive validity of the LapMentor basic skill tasks, supporting their possible usefulness for the preclinical evaluation of laparoscopic skills.

Evaluation of 2,590 urological laparoscopic surgeries undertaken by urological surgeons accredited by an endoscopic surgical skill qualification system in urological laparoscopy in Japan.

BACKGROUND: In 2003, the Japanese Urological Association (JUA) and Japanese Society of Endourology (JSE) established a urological laparoscopic skill qualification system, called the Endoscopic Surgical Skill Qualification System in Urological Laparoscopy of JUA and JSE (ESSQSJJ). The main goal of the system is to decrease the prevalence of complications associated with laparoscopic surgery. To validate the qualification system, perioperative outcome and the prevalence of complications in different types of urological laparoscopic surgery performed by accredited surgeons were evaluated. METHODS: One hundred thirty-six surgeons who obtained the qualification in 2004 were prospectively asked to submit intraoperative and postoperative data of their latest 20 cases at the end of 2009, along with the number of laparoscopic urological surgeries performed in each year for a 5-year period (2004-2009). Intraoperative and postoperative complications were graded according to the Satava classification and modified Clavien classification, respectively. RESULTS: Data of 2,590 urological laparoscopic surgeries of 130 surgeons, including 904 laparoscopic radical nephrectomies, 430 laparoscopic nephroureterectomies, 390 laparoscopic adrenalectomies, 320 laparoscopic radical prostatectomies, and 170 laparoscopic partial nephrectomies, were analyzed. Complications were noted in 97 (3.7%) patients. Major intraoperative complications (grade II or III) occurred in 32 (1.2%) patients, and major postoperative complications (grade III or higher) occurred in 24 (0.9%) patients. The prevalence of conversion to open surgery, allogeneic transfusion, and perioperative mortality was 2.5%, 1.6%, and 0%, respectively. The number of surgeries performed by each qualified surgeon or the role of the surgeon (main operator vs. mentor/instructor) in the surgery did not affect the prevalence of intraoperative complications or postoperative complications. The open conversion rate was significantly higher in surgeons with a low surgical volume. CONCLUSIONS: ESSQSJJ can ensure urological laparoscopic surgeons who can perform various types of urological laparoscopic surgeries with a low prevalence of perioperative complications and reasonable outcomes.

How many cases are necessary to develop competence for laparoscopic radical nephrectomy?

PURPOSE: We evaluated the number of cases necessary to develop competence for performing laparoscopic radical nephrectomy (LRN) by chronologically analyzing the results of 150 cases. PATIENTS AND METHODS: 150 patients were included in this study, each of whom had had pure transperitoneal LRNs between March 2003 and February 2008 performed by three surgeons who were all novices in laparoscopic surgery. Each surgeon performed 50 LRNs. These were divided into 10 groups chronologically, with five cases in each group (individual-group). Subsequently, we combined the data of the three surgeons, with 15 cases assigned to each group (combined-group). We identified the groups that demonstrated a statistically significant difference in operative time, compared with the most recent group. Based on this finding, we divided the cases into two groups: The novice group and the competent group. The complication rate, transfusion rate, and estimated blood loss were then compared between the two groups. RESULTS: The total average operative time was 187.6 +/- 46.56 minutes; from group 4 onward, there was no significant decrease in the operative time. Therefore, groups 1 to 3 were defined as the novice groups, and groups 4 to 10 as the competent groups. Incidence of intraoperative complications was six (13.3%) in the novice group and nine (8.6%) in the competent group. There were 14 cases with postoperative complications--4 (8.9%) in the novice group and 10 (9.5%) in the competent group. There were significant differences in the estimated blood loss and transfusion rate between the novice and competent groups (236.4 +/- 41.85 mL vs 191.5 +/- 21.9 mL, 17.8% vs 4.8%, respectively). CONCLUSIONS: Our results suggest that 15 cases are needed for a novice surgeon to achieve competence in LRN. Surgical outcomes and morbidity can be improved once this learning curve has been overcome.

Laparoscopic radical nephrectomy for large renal-cell carcinomas.

OBJECTIVES: We retrospectively reviewed the clinical outcome and long-term cancer control of patients with localized large renal-cell carcinomas (RCCs) who underwent laparoscopic radical nephrectomy in comparison to open procedure. PATIENTS AND METHODS: One hundred and thirty-one patients with RCCs greater than 7 cm who underwent radical nephrectomy between 1996 and 2008 were studied: 52 patients in the laparoscopy group and 79 in the open group. In this analysis patients who had metastasis or pT4 disease or tumor thrombus in the inferior vena cava were excluded. The median follow-up period was 41 months in the laparoscopy group and 51 months in the open group. RESULTS: Patients in the laparoscopy group had tumors similar in size to those in the open group (88 and 89 mm, respectively), lesser blood loss (245 and 663 mL p < 0.01), but more intraoperative complications (15% and 2.5%). One laparoscopy patient was converted to open surgery because of an injury to the inferior vena cava (IVC). The 5- and 10-year disease-free rates and patient-survival rates were comparable in both groups. CONCLUSIONS: Laparoscopic nephrectomy is feasible for localized large RCC, although intraoperative complications were more frequent. No statistically significant differences were found in either disease-free or cause-specific patient survival rates between the laparoscopy and the open groups. Laparoscopic nephrectomy can be an alternative to the open procedure for localized large RCC. However, a longer follow-up period is necessary to confirm the oncological efficacy of this procedure.

Laparoscopic versus open radical prostatectomy: urodynamic evaluation of vesicourethral function.

OBJECTIVES: To assess the impact of laparoscopic radical prostatectomy on vesicourethral function and compare it to that of open radical prostatectomy. METHODS: Sixty-three patients undergoing laparoscopic radical prostatectomy for localized prostate cancer were included in this retrospective analysis. Urodynamic parameters, including maximum urethral closing pressure (MUCP), functional profile length (FPL), bladder compliance, maximum cystometric capacity (MCC) and detrusor overactivity, were considered. Continence status and changes in urodynamic findings before and after surgery were evaluated. In addition, postoperative urodynamic findings were compared with those in 58 patients undergoing open radical prostatectomy. RESULTS: After laparoscopic radical prostatectomy, MUCP and FPL showed a significant postoperative decrease. Continence rates after surgery were 82% in the laparoscopic and 78% in the open group. Comparison of postoperative data between continent and incontinent patients in both surgical groups showed significantly lower MUCP, shorter FPL, lower bladder compliance and higher incidence of detrusor overactivity in incontinent patients. Although there was no significant difference in postoperative MUCP and FPL between the two groups, bladder compliance was significantly lower and incidence of detrusor overactivity was significantly higher in the open prostatectomy group. CONCLUSIONS: Laparoscopic radical prostatectomy has a negative impact on storage function by impairing function of the urethral sphincter and decreasing bladder compliance. There is no difference in postoperative urethral function between open and laparoscopic radical prostatectomy. Laparoscopic surgery might be associated with less impairment of bladder function than open surgery.

Laparoscopic radical nephroureterectomy: a multicenter analysis in Japan.

BACKGROUND: Laparoscopic nephroureterectomy (LNUx) is prevalent in Japan and throughout the world, but long-term outcome data remain limited. OBJECTIVE: To understand the present state of LNUx in Japan, we conducted a multicenter analysis of clinical outcome and long-term cancer control for patients who underwent the procedure. DESIGN, SETTING, AND PARTICIPANTS: Between January 1995 and December 2005, 1003 patients with urothelial cancer in the upper urinary tract were treated with LNUx at 51 institutions in Japan, and patient data were collected retrospectively. MEASUREMENTS: Patient profiles were gathered and analyzed for survival, intravesical recurrence, and risk factors influencing them. RESULTS AND LIMITATIONS: Median operative time was 320 min. Median bleeding volume was 232 ml. Complications occurred in 93 cases (9.3%) intraoperatively and in 107 cases (10.7%) postoperatively. Overall survival rate was 70% at 5 yr. Grade 3, pT3 or pT4, multifocal tumor, lymph-node metastasis, and previous or coexistent bladder tumor were independent risk factors for overall survival. Intravesical recurrence rate was 43% at 5 yr. Intravesical recurrence occurred more frequently in males, in patients with multifocal tumors, in patients with previous or coexistent bladder tumors, and in patients who underwent the hand-assisted approach. CONCLUSIONS: Our report represents the largest multicenter analysis of LNUx reported to date. Male sex and the use of the hand-assisted approach were shown for the first time to be risk factors for recurrence-free survival and intravesical recurrence. To further analyze the effectiveness of LNUx, a long-term outcome comparison with risk stratification must be made between LNUx and open nephroureterectomy.

Pure laparoscopic complete excision of distal ureter with a bladder cuff for upper tract urothelial carcinoma.

PURPOSE: In laparoscopic nephroureterectomy for upper tract urothelial carcinoma techniques for removing the lower ureter with a bladder cuff have been a matter of debate. We have developed a pure laparoscopic technique for the complete resection of the lower ureter with a bladder cuff. MATERIALS AND METHODS: Laparoscopic nephroureterectomy was performed in ten patients with upper tract urothelial carcinoma using this technique. After a working space was made retroperitoneally, the ureter was ligated at the distal site of the tumor. Retracting the ureter cranially, a stay suture was placed at an anterior point on the bladder and the bladder opened. With the patient placed in a lateral position, there was no urine leakage from the opened bladder. The ureteral orifice was confirmed laparoscopically. Incising around the ureteral orifice, the distal ureter was detached with the bladder cuff. The opened bladder wall was closed with running stitches. RESULTS: This method was technically successful in these ten cases with minimal bleeding and average operative time of 87 min. The margins of the bladder cuff were all negative and the average follow-up period of 19 months revealed only one (10%) bladder tumor recurrence. CONCLUSIONS: The ligation of the distal part of the ureter and the complete excision of the ipsilateral orifice and a bladder cuff under laparoscopic vision could reduce bladder tumor recurrence. Although this is a limited study with a small sample, the observation of low rates of bladder tumor recurrence after 19 months warrants further study.

Renal L-type fatty acid--binding protein in acute ischemic injury.

Fatty acid-binding proteins (FABPs) bind unsaturated fatty acids and lipid peroxidation products during tissue injury from hypoxia. We evaluated the potential role of L-type FABP (L-FABP) as a biomarker of renal ischemia in both human kidney transplant patients and animal models. Urinary L-FABP levels were measured in the first urine produced from 12 living-related kidney transplant patients immediately after reperfusion of their transplanted organs, and intravital video analysis of peritubular capillary blood flow was performed simultaneously. A significant direct correlation was found between urinary L-FABP level and both peritubular capillary blood flow and the ischemic time of the transplanted kidney (both P < 0.0001), as well as hospital stay (P < 0.05). In human-L-FABP transgenic mice subjected to ischemia-reperfusion injury, immunohistological analyses demonstrated the transition of L-FABP from the cytoplasm of proximal tubular cells to the tubular lumen. In addition, after injury, these transgenic mice demonstrated lower blood urea nitrogen levels and less histological injury than injured wild-type mice, likely due to a reduction of tissue hypoxia. In vitro experiments using a stable cell line of mouse proximal tubule cells transfected with h-L-FABP cDNA showed reduction of oxidative stress during hypoxia compared to untransfected cells. Taken together, these data show that increased urinary L-FABP after ischemic-reperfusion injury may find future use as a biomarker of acute ischemic injury.

Laparoscopic partial nephrectomy in upper-pole apical renal tumor using gauze sling and flexible laparoscope.

Upper-pole apical renal tumors are difficult to see using conventional rigid laparoscopes during laparoscopic partial nephrectomy. Added to this, the instrument angle makes tumor excision and kidney reconstruction difficult. We therefore elevated the kidney using a gauze sling and observed the lesion through a flexible laparoscope. With a clear field of vision, we could excise tumors and repair the kidney more easily.

Effects of olprinone, a phosphodiesterase III inhibitor, on ischemic acute renal failure.

OBJECTIVE: Renal ischemic reperfusion injury (IRI) is unavoidable and is still one of the major problems in renal transplantation. The aim of this study was to investigate the effects of olprinone, a phosphodiesterase III inhibitor, on renal IRI. METHODS: After a right nephrectomy, renal IRI was induced in rats. Olprinone was given in two different ways: sustained systemic administration and transient local administration to the kidney. Control rats were treated with saline. Using a magnifying endoscope, the renal blood flow speed was measured at 23 h after reperfusion. Then, blood samples were collected, and kidney specimens were taken for histological study. In order to study the mechanism, we performed in vitro experiments, using human proximal renal tubular cells (HK-2) incubated with tumor necrosis factor (TNF)-alpha along with olprinone or saline, and interleukin (IL)-8 was measured in the culture supernatant. RESULTS: In the saline group, the blood flow speed (BFS) was greatly reduced compared to that in normal kidneys. In both olprinone-treated groups, BFS of the renal microcirculation significantly increased, tubular damage and macrophage infiltration attenuated, and renal function greatly improved. Olprinone inhibited the increase in the IL-8 levels resulting from the incubation of HK-2 with TNF-alpha. CONCLUSIONS: Our study successfully demonstrates that olprinone has renoprotective properties when applied locally as well as systemically. The results suggest that olprinone might be clinically useful in renal transplantation for the donor kidney, the recipient, and even in treating acute renal failure.

Organ intact retrieval via umbilical incision after simultaneous bilateral laparoscopic radical nephrectomy for renal masses.

PURPOSE: We report on two cases of laparoscopic bilateral nephrectomy for renal-cell carcinoma (RCC) in patients with end-stage renal disease. PATIENTS AND METHODS: Bilateral renal masses were detected in two patients with acquired renal cystic disease. They underwent bilateral laparoscopic nephrectomy. The specimens were removed intact via an umbilical incision. RESULTS: The operative times were 8 hours and 6 hours and the estimated blood loss was 154 mL and 120 mL. Both patients resumed oral intake on postoperative day 1 and were discharged on postoperative day 6. No intraoperative and postoperative complications occurred. The pathology report revealed bilateral RCC. The original length of the umbilical incision was 4 cm which shrank to 3 cm by 2 months after the operation. CONCLUSIONS: Bilateral laparoscopic radical nephrectomy including intact organ retrieval for bilateral renal masses via a small umbilical incision is feasible.

[Two cases of bilateral renal cell carcinoma in patients with Von Hipple-Lindau disease].

Von Hipple-Lindau (VHL) disease is a rare familial cancer syndrome that is dominantly inherited and pre-disposes affected individuals to developing various tumors, including hemangioblastoma of the retina and central nervous system, and multicentric renal cell carcinoma. We report two cases of VHL disease with bilateral renal cell carcinoma. Case 1: A 53-year-old woman was referred to our hospital because of bilateral kidney tumor incidentally found. We performed left laparoscopic radical nephrectomy and laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation for the right kidney. Case 2: A 43-year-old woman was referred to our hospital because of left kidney tumor incidentally found. Because the suspectious lesion in the right kidney was very small, we decided to follow it up with no treatment. We performed laparoscopic nephrectomy, ex vivo excision and reconstruction, and autotransplantation for left kidney.

Identification and expression of a sialyltransferase responsible for the synthesis of disialylgalactosylgloboside in normal and malignant kidney cells: downregulation of ST6GalNAc VI in renal cancers.

Although disialyl glycosphingolipids such as GD3 and GD2 have been considered to be associated with malignant tumours, whether branched-type disialyl glycosphingolipids show such an association is not well understood. We investigated the sialyltransferases responsible for the biosynthesis of DSGG (disialylgalactosylgloboside) from MSGG (monosialylgalactosylgloboside). Among six GalNAc:alpha2,6-sialyltransferases cloned to date, we focused on ST6GalNAc III, V and VI, which utilize sialylglycolipids as substrates. In vitro enzyme analyses revealed that ST6GalNAc III and VI generated DSGG from MSGG with V(max)/K(m) values of 1.91 and 4.16 respectively. Transfection of the cDNA expression vectors for these enzymes resulted in DSGG expression in a renal cancer cell line. Although both ST6GalNAc III and VI genes were expressed in normal kidney cells, the expression profiles of ST6GalNAc VI among 20 renal cancer cell lines correlated clearly with those of DSGG, suggesting that the sialyltransferase involved in the synthesis of DSGG in the kidney is ST6GalNAc-VI. ST6GalNAc-VI and DSGG were found in proximal tubule epithelial cells in normal kidney tissues, while they were downregulated in renal cancer cell lines and cancer tissues. All these findings indicated that DSGG was suppressed during the malignant transformation of the proximal tubules as a maturation arrest of glycosylation.

The endoscopic surgical skill qualification system in urological laparoscopy: a novel system in Japan.

PURPOSE: The Japanese Urological Association, and Japanese Society of Endourology and ESWL have established the Endoscopic Surgical Skill Qualification System in urological laparoscopy. The system consists of a urological section as well as gynecology and general surgery sections. We present details of the Endoscopic Surgical Skill Qualification System and year 1 results. MATERIALS AND METHODS: Endoscopic Surgical Skill Qualification System requirements test the ability to complete common laparoscopic surgeries in each field. In urology applicants are required to complete adrenalectomies or nephrectomies appropriately and safely. Applicants should have 2 years of experience with laparoscopic practice, in addition to having completed a 6-year formal urological training program. Also, each surgeon must have performed more than 20 laparoscopic surgeries. According to assessment guidelines applicant skills are assessed by 2 referees who view unedited videotapes showing the entire laparoscopic procedure. To establish these referees 6 expert referees were first selected and 23 were then chosen from 36 referee applicants. Each referee had completed more than 100 laparoscopic surgeries and was chosen after video assessments by the 6 initial expert referees. RESULTS: Of 5,600 certified urologists in Japan 205 applied to this system in its first year, including 6 expert referees and 36 referee applicants. After video assessments by the referees 136 applicants were certified as having appropriate skills, resulting in a 66% pass rate. CONCLUSIONS: The Endoscopic Surgical Skill Qualification System has just started but it has drawn a lot of attention from the public. We hope that this qualification system will help prevent complications of urological laparoscopic surgeries and promote safer surgical procedures.

[Endoscopic trigonoplasty II for primary vesico-ureteral reflux].

PURPOSE: We report a technique and outcome of endoscopic trigonoplasty II (ET II), anti-reflux surgery via a transvesicostomy transurethral approach and discuss its usefulness. MATERIALS AND METHODS: Fifteen female patients, aged 5 to 64, with 23 refluxing ureters (grade I : 5, II : 2, III : 14, IV : 2) underwent the ET II. The principle of this surgery is tightening the muscular backing and elongating the intramural ureter. The operation consists of three steps: 1) two 5 mm locking trocars are placed into the bladder, 2) irrigating with 3% D-sorbitol solution, the bladder wall is incised upward along each side of the ureter using a resectoscope, to make a 2 to 3 cm U-shaped bladder flap including the ureter, 3) under a pneumobladder, the incised wall is sutured to make a muscular bed with a needle-holder via the urethra and forceps via the abdominal trocar. The U-shaped flap is fixed with two distal anchor sutures and four additional mucosal sutures. Urethral catheter is indwelled and the operation is finished. In recent four cases, we closed the tracts endoscopically. RESULTS: The average operative time was 144 minutes per ureter. In one patient with unilateral reflux, we switched to open surgery because of bleeding. Of 22 refluxing ureters, the reflux disappeared in 18 ureters (82%) and improved grade III to I in 1 ureter (5%) after 3 months and disappeared in 19 ureters (86%) after 12 months postoperatively. Ureteral injury was occurred in 3 patients during the transurethral incision of the bladder. Though we repaired it by placing a double-J stent in the 2 patients, reflux recurred in 12 months postoperatively in one of them. In the other patient cystoscopy revealed a vesicoureteral fistula in the injured portion. She subsequently underwent successful open Politano-Leadbetter ureteroneocystostomy. The average duration of indwelling catheter was shortened from 4.3 to 3.0 days by closing the tracts endoscopically. CONCLUSIONS: The overall cessation rate of the ET II was inferior to those of open anti-reflux surgeries or laparoscopic extravesical ureteral reimplantation. We do not recommend ET II for vesicoureteral reflux.

Laparoscopic nephroureterectomy for transitional cell carcinoma of renal pelvis and ureter: Nagoya experience.

OBJECTIVES: To evaluate the efficacy of retroperitoneoscopic nephroureterectomy for transitional cell carcinoma of the renal pelvis and ureter, we analyzed the clinical outcomes and long-term cancer control of 89 patients. METHODS: In 36 patients, the kidney was retroperitoneoscopically dissected and the ureteral end was resected with open procedure (combined laparoscopy group). In 53 patients, the ureteral end with a bladder cuff was transected using an endoscopic stapler (pure laparoscopy group). Sixty patients underwent open nephroureterectomy (open group). The median follow-up period was 35, 31, and 17 months in the open, combined, and pure laparoscopy groups, respectively. RESULTS: The average operative time and bleeding volume was 5.4 hours and 665 mL in the open group, 5.1 hours and 580 mL in the combined laparoscopy group, and 4.3 hours and 354 mL in the pure laparoscopy group, respectively. The cause-specific patient survival rate at 3 years was 81% in the open group, 86% in the combined laparoscopy group, and 80% in the pure laparoscopy group. The bladder recurrence-free rate at 3 years was 51% in the open group, 65% in the combined laparoscopy group, and 45% in the pure laparoscopy group. The extravesical recurrence-free rate at 3 years was 71% in the open surgery group, 76% in the combined laparoscopy group, and 71% in the pure laparoscopy group. No statistically significant difference was seen in patient survival, bladder recurrence, or extravesical recurrence rates among the three groups. CONCLUSIONS: Our retroperitoneal laparoscopic nephroureterectomy is less invasive than open surgery and is a safe and effective alternative.

[Renal transplantation].

Recent immunosuppressive drugs, including mycophenolate mofetil and basiliximab in addition to calcineurin inhibitors, have reduced the incidence and severity of acute allograft rejection in kidney transplants. This article introduces newly developed agents such as CTLA4-Ig, LEA29Y, rituximab, and FTY720 and also reviews immunosuppressive protocols which withdraw steroid or calcineurin inhibitors. Unrelated or ABO incompatible living donor kidney transplants have increased due to advancement of immunosuppressive

Herpes simplex virus type 1 mutant HF10 oncolytic viral therapy for bladder cancer.

OBJECTIVES: To investigate the antitumor effects of the oncolytic herpes simplex virus (HSV) type 1 mutant HF10 on human and murine bladder cancer cells (T24 and MBT-2) in vitro and in immunocompetent mouse models. METHODS: In vitro viral oncolytic activity and the replication ability of HF10 were measured in T24 and MBT-2 cells. To evaluate the therapeutic efficacy of HF10, disseminated peritoneal and bladder cancer models using MBT-2 cells were established in C3H/HeJ mice. The therapeutic efficacy was estimated from the survival rates and histopathologic analyses. RESULTS: HF10 replicated well in both T24 and MBT-2 cells, and it induced extensive cell lysis. Treatment with HF10 significantly prolonged the survival periods and increased the survival rates in both models tested. Immunohistochemical studies showed that HSV antigens were detected in the bladders 1 and 3 days after intravesical treatment with HF10 in nonimmunized mice, but only at 1 day after HF10 treatment in preimmunized, HSV-1 antibody-positive mice. A large number of inflammatory cells infiltrated into the bladder mucosa at 3 days after HF10 treatment in the preimmunized mice. CONCLUSIONS: These results suggest that HF10, a novel oncolytic HSV-1 mutant, is a promising agent for the treatment of superficial bladder cancer.