Prospective comparison of the immunological and stress response following laparoscopic and open surgery for localized renal cell carcinoma

Decreased renal function increases the nighttime urine volume rate by carryover of salt excretion to the nighttime

To determine the pathophysiology of nocturnal polyuria associated with renal dysfunction, patients who underwent laparoscopic nephrectomy were prospectively studied. The diurnal variation in urine volume, osmolality, and salt excretion were measured on preoperative day 2 and postoperative day 7. The factors associated with an increase in the nighttime urine volume rate with decreased renal function were evaluated using multiple linear regression analysis. Forty-nine patients were included. The estimated glomerular filtration rate decreased from 73.3 ± 2.0 to 47.2 ± 1.6 mL/min/1.73 m² (P < 0.01) and the nighttime urine volume rate increased from 40.6% ± 2.0% to 45.3% ± 1.5% (P = 0.04) with nephrectomy. The nighttime urine osmolality decreased from 273 ± 15 to 212 ± 10 mOsm/kg and the nighttime salt excretion rate increased from 38.7% ± 2.1% to 48.8% ± 1.7% (both P < 0.01) with nephrectomy. Multiple linear regression analysis showed that the increase in the nighttime urine volume rate was strongly affected by the increase in the nighttime salt excretion rate. A decrease in renal function causes an increase in the nighttime urine volume rate, mainly because of an increase in nighttime salt excretion.

Trial registration number: UMIN000036760 (University Hospital Medical Information Network Clinical Trials Registry).

Date of registration: From 1 June 2019 to 31 October 2020.

Management of colon-invading renal cell carcinoma: Operative technique and systematic review

Invasion into adjacent organs by non-metastatic renal cell carcinoma (RCC) occurs in 1% of patients suitable for resection. Colonic invasion is rare and presents technical challenges. No prospective data exists to guide management of these patients. We present the first reported case of a colon-invading RCC managed with simultaneous open right radical nephrectomy and extended right hemicolectomy. PubMed, Scopus and EMBASE databases were searched for relevant case reports reporting management of colon-invading renal cell carcinoma. Case reports, case series and cohort studies were eligible. A chart review was performed on a patient who presented with right-sided colon-invading RCC. Four previously reported cases were identified. The current case was managed with simultaneous open radical nephrectomy and extended right hemicolectomy. The patient remains well six months postoperatively with no evidence of disease recurrence. Histopathological evaluation of the resected specimen confirmed a T4 clear cell RCC with sarcomatoid differentiation. Colon-invading RCC is rare. This is the first reported case of right-sided, colon-invading RCC treated with radical resection. The current case confirms radical resection is a feasible management strategy for similar presentations. En bloc resection of involved organs remains the only potentially curative option for locally advanced disease.

The perioperative period: a critical yet neglected time window for reducing the recurrence risk of endometriosis?

While surgery is commonly the management of symptomatic endometriosis when patients do not respond to medical or supportive therapy, recurrence after surgery poses a serious challenge, and repeat surgery increases the risk of premature ovarian failure, adhesion and organ injury. Conceivably, the recurrent endometriotic lesions could arise from minimal residual lesions (MRLs) or from de novo lesions. However, several lines of evidence suggest that the former is more likely. So far, most, if not all, efforts to combat recurrence have been focused on postoperative medication of hormonal drugs to reduce recurrence risk through lesional dormancy and possibly atrophy. However, the perioperative period may exert a disproportionally high impact on the risk of recurrence; it is likely to be amendable for possible intervention but has been generally neglected. Indeed, many perioperative factors are known to or conceivably could facilitate the recurrence of endometriosis through the suppression of cell-mediated immunity due to the activation of adrenergic signaling and the release of prostaglandins. Perioperative use of β-blockers and/or nuclear factor κB/jCycloxygenase 2 (NF-κB/COX-2) inhibitors may boost the cell-mediated immunity suppressed by surgery, resulting in the partial or even complete removal of MRLs and reduced recurrence risk. This is both biologically plausible and supported by a recent experimental study. We call for more research on possible perioperative interventions to reduce the recurrence risk of endometriosis. The potential payoff might be a substantial reduction in the risk of recurrence and cost when compared with the traditional approach of postoperative intervention.

Exploiting the critical perioperative period to improve long-term cancer outcomes

Evidence suggests that the perioperative period and the excision of the primary tumour can promote the development of metastases—the main cause of cancer-related mortality. This Review first presents the assertion that the perioperative timeframe is pivotal in determining long-term cancer outcomes, disproportionally to its short duration (days to weeks). We then analyse the various aspects of surgery, and their consequent paracrine and neuroendocrine responses, which could facilitate the metastatic process by directly affecting malignant tissues, and/or through indirect pathways, such as immunological perturbations. We address the influences of surgery-related anxiety and stress, nutritional status, anaesthetics and analgesics, hypothermia, blood transfusion, tissue damage, and levels of sex hormones, and point at some as probable deleterious factors. Through understanding these processes and reviewing empirical evidence, we provide suggestions for potential new perioperative approaches and interventions aimed at attenuating deleterious processes and ultimately improving treatment outcomes. Specifically, we highlight excess perioperative release of catecholamines and prostaglandins as key deleterious mediators of surgery, and we recommend blockade of these responses during the perioperative period, as well as other low-risk, low-cost interventions. The measures described in this Review could transform the perioperative timeframe from a prominent facilitator of metastatic progression, to a window of opportunity for arresting and/or eliminating residual disease, potentially improving long-term survival rates in patients with cancer.

Development of urologic laparoscopy in Germany, Austria, and Switzerland: a survey among urologists

PURPOSE

Laparoscopy introduction has dramatically changed urology. Novel techniques, such as laparoendoscopic single-site surgery (LESS) and natural orifice translumenal endoscopic surgery (NOTES), might also have substantial influence. This 2012 survey evaluated present laparoscopy use, its appraisal among urologic surgeons, laparoscopy training, and use of new techniques. Results were compared to the previous surveys, demonstrating the 10-year development of laparoscopy.

METHODS

A detailed questionnaire regarding demographic data, laparoscopy use, attitudes concerning laparoscopy, and novel techniques was send to 424 departments in Germany, Austria, and Switzerland. Procedures performed in 25 indications were quantitatively evaluated.

RESULTS

The response rate was 63 % (269). Eighty-six percent of the respondents reported performing laparoscopy, compared to 54 % in 2002. Only 16 % expected economic advantages with laparoscopy, whereas 67 % expected shorter hospitalization. Seventy percent of responders anticipated comparable functional and oncological results between laparoscopic procedures and open surgery. Slow learning curves (81 %) and insufficient training facilities (32 %) were reported to impair laparoscopic surgery. On average, laparoscopic and non-laparoscopic surgical teams consisted of 2.5 and 3.5 members, respectively. LESS procedures were performed at 15 % of institutions. Twenty-two percent of respondents considered NOTES techniques valuable for future urology. Few indications (laparoscopic prostatectomies or nephrectomies) were performed frequently in specialized centers, and the rapidly increasing procedure numbers observed between 2002 and 2007 had dropped to a mild accretion. The results demonstrate broad acceptance of laparoscopy in German urologic surgery, depict the need for structured training facilities, and indicate limited impact of novel techniques (LESS and NOTES).

CONCLUSIONS

The survey demonstrates the 10-year development of urologic laparoscopy and the broad acceptance of laparoscopic techniques.

Systemic immunologic and inflammatory response after laparoscopic versus open nephrectomy: a prospective cohort trial

PURPOSE

To compare the dynamics of systemic inflammatory indices during laparoscopic nephrectomy (LN) and standard open donor nephrectomy.

PATIENTS AND METHODS

Participants in this cohort study were 54 adults without a history of renal surgery and no evidence of urinary tract infection who underwent transperitoneal LN (n=29) and open donor nephrectomy (n=25, control group). We recorded demographic characteristics, intraoperative parameters, and changes 24 hours postoperatively in systemic inflammatory and immunologic values (body temperature, concentrations of white blood cell count [WBC], C-reactive protein [CRP], interleukin [IL]-6, and tumor necrosis factor [TNF]-α), and compared the mean changes between groups.

RESULTS

Mean age was older in the LN group (45.6 vs 30.9 years; P<0.0001), and mean operative time was significantly shorter (83.1 min vs 101.6 min; P=0.004). Mean postoperative increase in IL-6 and body temperature in LN was significantly less than in control: For IL-6, 15.87 vs 29.09 pg/mL, P=0.03; for body temperature, +0.22°C vs +0.71°C, P=0.001). Mean postoperative increases in levels of other inflammatory markers (CRP, TNF-α, WBC) did not differ significantly. No statistical correlation was found between operative time and changes in IL-6, CRP, TNF-α, WBC, or body temperature.

CONCLUSION

Based on the smaller increase in serum IL-6 as the most important indicator of surgical stress, the surgical trauma-induced immune dysfunction may be less intense after LN than open surgery. This may explain the smooth convalescence after LN.

Early immune outcome of retroperitoneal laparoscopic radical nephrectomy for localized renal cell carcinoma: a prospective, randomized study

OBJECTIVES

We evaluated differences in cytokine responses and T-lymphocyte subsets following retroperitoneal laparoscopic and conventional open radical nephrectomies for localized renal cell carcinoma (RCC).

METHODS

A total of 62 patients with T(1)N(0)M(0) staged RCC were randomized to either retro-laparoscopic (n = 31) or open (n = 31) radical nephrectomy. Plasma levels of interleukin-1β (IL-1β), IL-6, and tumour necrosis factor-alpha (TNF-α) were measured separately by enzyme linked immunosorbent assay (ELISA) preoperatively and on postoperative days 1 and 5. Levels of CD3(+), CD4(+) and CD8(+) as well as the CD4(+):CD8(+) ratio were acquired by flow cytometry at the same time points.

RESULTS

Levels of IL-1β, IL-6 and TNF-α increased significantly compared to preoperative values in both groups (p < 0.05) on postoperative day 1, and all the parameters in the open group were significantly higher than those in the retro-laparoscopy group (p < 0.05). On postoperative day 1, the levels of CD3(+) and CD4(+) and the CD4(+):CD8(+) ratio decreased markedly compared to preoperative values for both groups (p < 0.05). Elevations of the CD4(+):CD8(+) ratio in the retro-laparoscopy group (p < 0.05) and the CD8(+) level in the open group (p < 0.05) were observed when compared with the other group. On postoperative day 5, the levels of CD3(+) and CD4(+) and the CD4(+):CD8(+) ratio in the retro-laparoscopy group, as well as the level of CD8(+) in the open group, returned to about preoperative levels (p < 0.05). Follow-up ranged from 4 to 14 months postoperatively in all 62 patients with a 100% cancer-specific survival rate in both groups.

CONCLUSIONS

Retroperitoneal laparoscopic radical nephrectomy is associated with the milder cytokine responses caused by trauma and inflammation and the better preserved distribution of T-lymphocytes.

The difference of the impacts of surgical approaches on cellular immunity in patients with uterine malignancies: a comparative study of laparoscopy and laparotomy surgery

OBJECTIVE

To explore the impact of laparoscopy and laparotomy surgery on cellular immunity in patients with malignant uterine tumors.

METHODS

Thirty-eight women with uterine malignancies were enrolled in a prospective nonrandomized cohort study. Either laparoscopy or laparotomy was performed according to the patients' choice. The frequency of CD3+, CD4+, CD8+ T cells and natural killer cells derived from peripheral venous blood was evaluated by flow cytometry.

RESULTS

(1) Postoperatively, there was a decrease in the number of lymphocyte counts, especially after laparotomy, on the first postoperative day (p < 0.01). (2) Compared with preoperative levels, the frequencies of CD3+ and CD4+ cells and the CD4+/CD8+ ratio were declined both in the laparoscopy and laparotomy groups on postoperative day 1 (p < 0.01). (3) The frequencies of CD3+ and CD4+ cells and the ratio of CD4+ to CD8+ cells were less depressed in the laparoscopy group on the first postoperative day (p < 0.05). (4) The frequency of natural killer cells increased, both in the laparoscopy and laparotomy groups on the first postoperative day (p < 0.01), but there were no significant differences between the two groups (p > 0.05).

CONCLUSION

Cellular immunity was temporally depressed in patients with uterine malignancy after surgical treatment, but laparoscopic surgery depressed the immunity less than laparotomy.

[Immune response during laparoscopic and open living donor nephrectomy. An experimental pig model]

INTRODUCTION

It's been demonstrated laparoscopic access determines a lower surgical stress, by measurement of several markers as different interleuquines (IL) or C-reactive protein (CRP). Endothelin 1 (ET-1) is a powerful vasoconstrictor produced in renal endothelium scarcely studied in laparoscopy. The objective of this study is to analyze immune response during laparoscopic and open donor nephrectomy, in a porcine experimental model by means of measuring IL-2, 10, tumoral necrosis factor alpha (TNFalpha), CRP and ET-1.

METHODS

Twenty pigs underwent left nephrectomy, 10 by laparoscopy and 10 by open approach in an experimental model. Both groups were monitorized IL-2, 10, TNF alpha, ET-1 at basal, immediately post surgery, first, third, fifth and seventh days after procedure.

RESULTS

The comparative analysis between groups demonstrated a significant increase in levels of CRP (1.44+/-0.88 vs 1.32+/-0.14 mg/dl, p=0.046), TNF alpha (131.14+/-41.37 vs 57.19+/-23.71 pg/ml, p>0.001) and ET-1 (0.91+/-0.49 vs 0.56+/-0.5 fmol/ml, p=0.001) of open nephrectomy group, as a higher levels of IL-2 in laparoscopic group.

CONCLUSIONS

Open donor nephrectomy determines a higher immune response than laparoscopic approach. The importance of this fact over the ischemia-reperfusion syndrome or the immediate function of graft is not clearly established.

Changes in circulating immunosuppressive cytokine levels of cancer patients after high intensity focused ultrasound treatment

Immunosuppression in a patient with malignant tumor is a major obstacle in cancer treatment. In this study, we investigated changes in the circulating level of all measured immunosuppressive cytokines in patients with malignancy before and after high intensity focused ultrasound (HIFU) treatment. Fifteen patients with solid malignancy were enrolled in this study and an enzyme-linked immunoabsorbent assay (ELISA) method was used to measure serum level of vascular endothelial growth factor (VEGF), transforming growth factor-beta1 (TGF-beta1), transforming growth factor-beta2 (TGF-beta2), interleukin 6 (IL-6) and interleukin 10 (IL-10), respectively before and 1 wk after HIFU treatment. Among them, seven patients had distant metastasis and the remaining eight had no metastasis. All patients received one-session HIFU treatment for primary cancer, including complete ablation in eight patients without metastasis, and partial ablation in seven patients with metastases. The results showed that serum immunosuppressive cytokine levels decreased after HIFU treatment, and there were significant decreases of VEGF, TGF-beta1, and TGF-beta2 before and after HIFU treatment. Compared with the values in the metastatic patients, serum levels of immunosuppressive cytokines were significantly lower in the nonmetastatic patients after HIFU treatment. It is concluded that HIFU can decrease tumor-secreted immunosuppressive cytokine production in addition to its direct tumor destruction. This change may lessen tumor-induced immunosuppression and renew antitumor immunity after HIFU in cancer patients.

Laparoscopic renal oncological surgery in the presence of abdominal aortic and vena caval pathology: 8-year experience

PURPOSE

To our knowledge the outcomes of laparoscopic renal oncological surgery in patients with major aortic and/or inferior vena caval pathology are unknown. We present our experience spanning an 8-year period.

MATERIALS AND METHODS

From March 1998 to October 2006, 1,826 laparoscopic renal procedures were performed for tumor. Of these patients 66 (3.6%) had major abdominal aortic or vena caval pathology concomitantly. Demographics, specific entities of the vascular disease, and intraoperative and postoperative data were reviewed.

RESULTS

A total of 66 patients had a history of abdominal aortic disease (54), vena caval disease (9) or both (3). Of the patients 85% had 3 or greater comorbidities, 88% had an American Society of Anesthesiologists score of 3 or greater and 88% were on chronic anticoagulation therapy. A total of 27 patients (41%) had undergone prior surgical treatment for vascular pathology. Laparoscopic renal surgery, which was transperitoneal in 25 cases and retroperitoneal in 41, included radical nephrectomy in 20, partial nephrectomy in 17 and cryoablation in 29. Open conversion was performed in 3 patients (5%). There were 3 intraoperative (5%) and 9 postoperative (14%) complications. One patient died of pulmonary sepsis. There was no statistically significant difference in perioperative outcomes between the aortic and vena caval disease groups. The retroperitoneal approach was associated with less blood loss and shorter operative time (p = 0.0003 and 0.004, respectively).

CONCLUSIONS

Laparoscopic surgery for renal tumor in the presence of aortic or vena caval disease is safe and feasible. Considerable prior laparoscopic experience is necessary when treating these patients at high risk.

Immunohumoral response during laparoscopic and open living donor nephrectomy: an experimental model

Measurement of interleukins (IL) and C-reactive protein (CRP) have demonstrated that a laparoscopic approach may induce less surgical stress than an open approach. The potential influence of this observation in living donor nephrectomy has scarcely been analyzed. The aim of the study was to analyze the immunohumoral response induced by laparoscopic versus open donor nephrectomy in an experimental model. Twenty pigs underwent left nephrectomy, 10 by laparoscopy and 10 by an open approach. In both groups the following parameters were measured: CRP, IL-2, IL-10, tumour necrosis factor alpha (TNF alpha), and endothelin-1 (ET-1). The determinations were done at different times: basal, immediately as well as on the first, third, fifth, and seventh days after the procedure. A comparative analysis between groups demonstrated a significant increases among the open group in the following markers: CRP (1.44 +/- 0.88 vs 1.32 +/- 0.14 mg/dL, P = .046); TNF alpha (131.14 +/- 41.37 vs 57.19 +/- 23.71 pg/mL; P > .001); and ET-1 (0.91 +/- 0.49 vs 0.56 +/- 0.5 fmol/mL; P = .001). The laparoscopic group showed higher levels of IL-2 than the open group. In conclusion, open donor nephrectomy produced a greater immunohumoral response than a laparoscopic approach. The influence of these observations on ischemia-reperfusion injury or on immediate graft function after kidney transplantation has not been clearly established.

Minimally invasive cancer surgery improves patient survival rates through less perioperative immunosuppression

The import of the immune system to cancer survival is paramount. Immune effector cells are intimately involved in the patient's response to cancer. People with decreased immune function develop cancer more frequently. In the early stages of solid organ malignancies, surgery can potentially be curative. Surgical intervention, in and of itself, is immunosuppressive. Surgical resections are traditionally performed through large incisions. Technologic advances have allowed minimally invasive surgery (MIS) to evolve to the point it is now being used for cancer treatment. Recent minimally invasive series have reported improved survival and recurrence rates, as compared with historical data. We hypothesized that outcome differences for cancer patients undergoing open surgery vs. MIS are due to differential inhibition of immune effector cell function, in response to the different surgical stimulus. This increased immunosuppression after open surgery could potentially inhibit immune effector cell tumor surveillance as well as inhibit scavenging of any residual or micrometastatic disease or of tumor cells shed at the time of the operation. The less immunosuppressive MIS may leave immune function above a threshold level where remaining tumor is cleared. This difference would lead to less recurrence and to survival advantages. A deeper understanding of the integral components of the immune response to surgery would open the door for immunomodulation strategies and be of great clinical utility in guiding neoadjuvant, surgical, or adjuvant therapeutic decisions.

Characterization and management of postoperative hemorrhage following upper retroperitoneal laparoscopic surgery

PURPOSE

Surgical paradigms may change in the era of laparoscopic surgery. We evaluated a conservative nonsurgical approach to postoperative hemorrhage following laparoscopic upper retroperitoneal surgery as opposed to the more traditional strategy of reexploring the surgical site.

MATERIALS AND METHODS

In 911 laparoscopic procedures performed in 8 years we retrospectively identified risk factors and characterized treatment for postoperative hemorrhage.

RESULTS

We considered postoperative hemorrhage to be present when postoperative transfusion was required that could not be accounted for by operative blood loss or another definable cause outside of the surgical field. Red blood cell transfusion was required after 53 procedures (5.8%), of which 34 (3.7%) were done for postoperative hemorrhage. Postoperative hemorrhage occurred only after nephrectomy in 3.3% of cases, after partial nephrectomy in 9.9% and after adrenalectomy in 5.4%. Multivariate analysis revealed a significant association of postoperative hemorrhage with patient age and American Society of Anesthesiologists score (preoperative factors), operative time and splenic injury (intraoperative factors), and gastrointestinal complications and prolonged hospitalization (postoperative factors). Postoperative hemorrhage increased mean hospitalization from 2.5 to 6.4 days. No significant differences in post-hospital recovery were associated with postoperative hemorrhage. Only 4 of the 34 patients (12%) required surgical management of postoperative hemorrhage. All other cases were conservatively managed. Outcome after surgical and conservative management did not differ except postoperative renal complications tended to be more common in the former cases (50% vs 7%).

CONCLUSIONS

Most patients with hemorrhage following laparoscopic upper retroperitoneal surgery can be treated with conservative nonsurgical interventions.

Cœlioscopie et cancer en gynécologie : le point en 2005

All the surgical procedures, which may be required to treat a gynecologic cancer, can be performed endoscopically. However prospective randomized studies required to confirm the oncologic efficacy of the technique are still lacking in gynecology, whereas such studies are available in digestive surgery. Animal studies suggested that the risk of tumor dissemination in non traumatized peritoneum is higher after a pneumoperitoneum than after a laparotomy. Experimental studies also emphasized two points: the surgeon and the surgical technique are essential, all the parameters of the pneumoperitoneum may influence the postoperative dissemination. Changing these parameters we may, in the future, be able to create a peritoneal environment adapted to oncologic patients in order to prevent or to decrease the risks of peritoneal dissemination and/or of postoperative tumor growth. Until the results of prospective randomized studies become available, the preoperative selection of the patients and the surgical technique should be very strict. In patients with endometrial cancer, the laparoscopic approach should be reserved to clinical stage I disease, if the vaginal extraction is anticipated to be easy accounting for the volume of the uterus and the local conditions. In cervical cancer, the laparoscopic approach should be reserved to patients with favorable prognostic factors: stage IB of less than 2 cm in diameter. Laparoscopy is the gold standard for the surgical diagnosis of adnexal masses. But the puncture should be avoided whenever possible. The surgical treatment of invasive ovarian cancer should be performed by laparotomy whatever the stage. In contrast restaging of an early ovarian cancer initially managed as a benign mass, is a good indication of the laparoscopic approach. The laparoscopic management of low malignant potential tumors should include a complete staging of the peritoneum. Knowledge of the principles of endoscopy and of oncologic surgery is required. Teaching and diffusion of endoscopic oncological techniques are among the major challenges of gynecologic surgery within the next few years.

Nefrectomía radical laparoscópica

In this article, we review the different surgical approaches to carry out radical laparoscopic nephrectomy: transperitoneal approach, retroperitoneal approach and hand-assisted approach. We describe the advantages and drawbacks of each alternative and summarize the most important references in the medical literature. In spite of this being a relatively new surgical approach, less than 15 years old, it has become a standard treatment and, today, is considered as the elective surgical treatment for T1 and T2 renal tumours in many centres.

Is minimal access surgery for cancer associated with immunologic benefits?

Minimal-access surgical techniques have been shown to be beneficial to patients in terms of shorter convalescence, reduced pain, and improved cosmesis. Although systemic immune function is better preserved following laparoscopic procedures when compared with their respective open approaches, CO2 pneumoperitoneum may significantly affect local (i.e., infra-abdominal) cellular immunity by reducing regional macrophage function. Results to date are conflicting with regard to the impact of closed and open methods on intraabdominal immunity. Impaired cellular immunity after CO2 pneumoperitoneum may have significant undesirable intra-abdominal effects on tumor surveillance after oncological surgery; however, at present, there is no clinical evidence to support this position. The VATS techniques avoid the use of CO2 insufflation, which may offer some advantages from the immune function perspective over laparoscopic procedures accomplished with CO2 pneumoperitoneum. Better preservation of early postoperative cellular immune function and attenuated disturbance in the inflammatory mediators are likely contributing factors to the clinical benefits that follow laparoscopic surgery and VATS. Larger multi-center randomized trials are needed to confirm the potential benefits of minimal-access surgery on patient survival after cancer surgery. Future research should focus on the effects of minimal-access surgery on other mediators (such as MMP-9, IGFBP-3, IL-12, IL-17, and IL-23) that may be important in tumor cell dissemination, deposition, and propagation in the early postoperative period. Furthermore, additional searches for other factors or mediators, heretofore unrecognized, should be carried out. Such studies will, we hope, increase our knowledge and understanding of the impact of surgery on immune and other physiologic functions.

Urological laparoscopy: basic physiological considerations and immunological consequences

PURPOSE

The applications of laparoscopy to urological surgery continue to grow at a steady pace. A complete understanding of the physiological and immunological changes associated with pneumoperitoneum is required. We reviewed the physiology of laparoscopy with regard to the major organ systems and summarize the effects of pneumoperitoneum on immune function.

MATERIALS AND METHODS

Articles published in the scientific literature from 1990 to 2004 with relevance to laparoscopic physiology and the immune response to pneumoperitoneum were reviewed using PubMed.

RESULTS

Pneumoperitoneum induces predictable pulmonary and renal responses. The cardiovascular and hemodynamic responses are phasic and dynamic in nature, and only generalizations regarding cardiac function can be made. Renal parenchymal and venous compression during pneumoperitoneum are the etiology of oliguria during laparoscopy. The effects are reversible and cause no adverse effects on renal function. There is a general trend toward systemic immune preservation and peritoneal immune depression during insufflation based laparoscopy. Attenuated peritoneal immunity has been demonstrated most consistently by altered macrophage function.

CONCLUSIONS

Physiological changes incurred as a result of pneumoperitoneum have minimal adverse effects in healthy individuals undergoing laparoscopic surgery. Interest has grown in the impaired peritoneal immune response to CO2 pneumoperitoneum. Altered intraperitoneal immunity may represent a new avenue for the development of adjuvant therapies for minimally invasive treatments of urological malignancies and for the prevention of port site metastasis. Further elucidation and investigation into the immunological responses to pneumoperitoneum during urological laparoscopic procedures is called for.

Comparison of the expressed porcine Vbeta and Jbeta repertoire of thymocytes and peripheral T cells

Transcripts of more than 300 unique T-cell receptor-beta (TCR-beta) V-D-J rearrangements recovered from porcine thymocytes and peripheral T cells were compared. We identified 19 groups (families) of porcine Vbeta genes in seven supergroups and provisionally named 17 groups based on their sequence similarity with recognized human Vbeta gene families. TRBV4S, 5S, 7S and 12S accounted for >80% of all Vbeta usage, and usage of these groups by thymocytes and peripheral T cells was highly correlated. No TRBV group was uniquely expressed in significant numbers in thymocytes, although small numbers of TRBV groups 2S, 9S and 15S were only recovered from T cells. Usage of Jbeta segments from the 5' D-J-C duplicon in thymocytes and peripheral T cells directly correlated with their 5' position in the locus, and Jbeta1.1, 1.2 and 1.3 accounted for >or= 35% of all Jbeta usage in both cell types. This contrasts with the usage of Jbeta2 segments in that Jbeta2.4, 2.5 and 2.7 accounted for approximately 30% of Jbeta usage by T cells and thymocytes. Jbeta2.7 was threefold more frequent among T cells than thymocytes. The Vbeta/Jbeta combination was not random. Jbeta1.1 and 1.2 were used in 29% of rearrangements with high frequency among the major Vbeta groups. Combinations of TRBV4 and V12 with Jbeta2.7 were only found in T cells and accounted for half of all Jbeta2.7 usage. These studies show that unlike porcine heavy chain V(H) genes, the occurrence and relative usage of porcine TCR-Vbeta groups resembles that of humans. Thus, highly related gene systems can individually diverge within a species.

Systemic stress responses in patients undergoing surgery for benign prostatic hyperplasia

OBJECTIVE

To determine differences in systemic stress responses in patients undergoing three different types of surgery for benign prostatic hyperplasia (BPH), evaluated by measuring levels of stress variables, i.e. cortisol; acute-phase reactants, i.e. C-reactive protein (CRP) and fibrinogen; and antioxidants, i.e. total antioxidant status (TAS) and superoxide dismutase (SOD).

PATIENTS AND METHODS

The study included 80 patients who fulfilled the inclusion criteria for surgery for BPH. Based on an ultrasonographic estimate of the prostate volume before surgery, all patients were allocated to one of three groups; group 1, prostate < or = 30 g and treated with transurethral incision of the prostate (TUIP); group 2, prostate 30-80 g, treated with transurethral resection of the prostate (TURP); and group 3, prostate >80 g, treated with a suprapubic transvesical prostatectomy (TP). Blood samples were taken from each patient on the day before and the day after surgery, and the acute-phase reactants and antioxidants measured; cortisol concentrations were also measured in 24-h urine samples the day before and 3 days after surgery.

RESULTS

There were significantly higher levels of cortisol, CRP and TAS, and significantly lower levels of fibrinogen and SOD in all study groups after surgery than before. Surgery and associated conditions, e.g. excitement, fear, blood loss, etc., lead to traumatic and oxidative stress, followed by a strong systemic stress response during and after surgery. Low fibrinogen levels after surgery had a different pattern from the other acute-phase reactants, as a result of increased fibrinolytic activity after TURP and TP.

CONCLUSION

The extent of the systemic stress response correlated fairly well with the degree of tissue damage, which differed in the three groups. Suprapubic TP caused the most tissue trauma and triggered the strongest systemic stress response. This response was moderate after TURP, while TUIP (a minor intervention) caused the least stress. Specific changes in stress markers could be used to improve surgery for BPH. Whether there is a benefit of antioxidant therapy during surgery for BPH should be evaluated in further studies.