Transperitoneal and retroperitoneal laparoscopic heminephrectomy--what approach for which patient?

PURPOSE: We report our experience with laparoscopic heminephrectomy using the transperitoneal and retroperitoneal approaches in 48 pediatric patients. MATERIALS AND METHODS: A total of 48 laparoscopic heminephrectomies were performed in 35 girls and 13 boys 45 days to 17 years old (mean 4.08 years) between September 1998 and March 2005. The procedures consisted of 44 upper pole heminephrectomies with partial or total ureterectomies and 4 lower pole heminephroureterectomies. Surgeries were performed using a transperitoneal approach in 32 patients (67%) and a retroperitoneal approach in 16 (33%). RESULTS: Followup ranged from 0.75 to 7.25 years (mean 3.53). In the retroperitoneal group 2 procedures required conversion, 1 to open heminephrectomy and 1 to a transperitoneal laparoscopic approach. Complications were seen in 5 of 48 patients (10%). Complications in the retroperitoneal group were seen in 2 patients. One patient had a postoperative urinary leak that resolved spontaneously. Another patient had development of a urinoma that was treated conservatively. Complications in the transperitoneal group were seen in 3 patients. One patient required an intraoperative chest tube due to pneumothorax, 1 had recurrent urinary tract infection that required excision of a short ureteral remnant and 1, 6-month-old boy had development of postoperative hypertension. Four of the 5 complications (80%) were seen in patients younger than 1 year. CONCLUSIONS: Transperitoneal and retroperitoneal laparoscopic heminephrectomy can be performed for benign disease in children with minimal morbidity, improved cosmesis and short hospital stay. Complication rate does not depend on the surgical approach, but rather on the age of the patient.

Acceleration of lpr lymphoproliferative and autoimmune disease by transgenic protein kinase CK2 alpha.

MRL-lpr/lpr mice have a Fas receptor mutation that leads to abnormalities of apoptosis, lymphoproliferation, and a lupus-like autoimmune disease associated with the production of autoantibodies. Other than Fas pathway defects, little is known about molecular abnormalities that predispose to autoimmunity. Protein kinase CK2 (also termed casein kinase II), a serine-threonine protein kinase whose targets include many critical regulators of cellular growth, is highly expressed in a lymphoproliferative disease of cattle and in many human cancers. Overexpression of the CK2alpha catalytic subunit in lymphocytes of transgenic mice leads to T cell lymphoma. We hypothesized that CK2 dysregulation and Fas mutation might cooperatively augment lymphocyte proliferation and transformation. We find that in MRL-lpr/lpr mice bearing the CK2alpha transgene, the lymphoproliferative process is dramatically exacerbated, as these mice develop massive splenomegaly and lymphadenopathy by 12 wk of age in association with increased autoantibody production and accelerated renal disease. The lymphoid organs are filled with the unusual B220+CD4-CD8- T cells typically seen in MRL-lpr/lpr mice, not the B220-CD4+CD8+ or B220-CD4-CD8+ T cells typically seen in CK2a transgenic lymphomas. The T cells do not fulfill the criteria for transformation, as they are polyclonal and not transplantable or immortal in cell culture. Thus, although the lpr lymphoproliferative and autoimmune syndrome is potentiated by the presence of the CK2a transgene, this combination of apoptotic and proliferative abnormalities appears to be insufficient to transform lymphoid cells.