Laparoscopic versus open nephrectomy in 210 consecutive patients: outcomes, cost, and changes in practice patterns.

BACKGROUND: Initially slow to gain widespread acceptance within the urological community, laparoscopic nephrectomy is now becoming the standard of care in many centers. Our institution has seen a dramatic transformation in practice patterns and patient outcomes in the 2 years following the introduction of laparoscopic nephrectomy. We compare the experience with laparoscopic and open nephrectomy within a single medical center. METHODS: Data were collected for all patients undergoing elective nephrectomy (live donor, radical, simple, partial, and nephroureterectomy) between August 1998 and September 2002. Data were analyzed by Wilcoxon rank sum, chi-square, and Fisher's exact test. A p-value <0.05 was considered significant. RESULTS: Of the patients, 92 underwent open nephrectomy, and 118 were treated laparoscopically (87 hand-assisted laparoscopic nephrectomy, 31 totally laparoscopic). There was one conversion (0.8%). Patient demographics and indications for surgery were equivalent for both groups. Mean operative time for laparoscopic nephrectomy (230 min) was longer than for open (187 min, p = 0.0001). Blood loss (97 ml vs 216 ml, p = 0.0001), length of stay (3.9 days vs 5.9 days, p = 0.0001), perioperative morbidity (14% vs 31%, p = 0.01), and wound complications (6.8% vs 27.1%, p = 0.0001) were all significantly less for laparoscopic nephrectomy. For live donors, time to convalescence was less (12 days vs 33 days, p = 0.02), but hospital charges were more for patients treated laparoscopically (19,007 dollars vs 13,581 dollars, p = 0.0001). CONCLUSIONS: Laparoscopic nephrectomy results in less blood loss, fewer hospital days, fewer complications, and more rapid recovery than open surgery. We believe that these benefits outweigh the higher hospital charges associated with the laparoscopic approach.

Continuing observations on the regulatory effects of donor-specific bone marrow cell infusions and chimerism in kidney transplant recipients.

BACKGROUND: Continued follow-up of a series of donor bone marrow cell (DBMC)-infused first cadaver renal transplant recipients is described (n=58), now at a 36-month actuarial time point postoperatively. Serial polymerase chain reaction-flow cytometry (PCR-Flow) and cellular immune assays of iliac crest bone marrow aspirates and peripheral blood have begun to be compared with concomitantly transplanted recipients of living-related donor (LRD) kidneys and donor marrow infusions given the same immunosuppressive regimen (n=16). There have also been comparisons (36 months) with 188 controls transplanted concomitantly, i.e., recipients of first cadaver kidney transplants, who did not receive bone marrow. METHODS: Each group was given equivalent immunosuppressive regimens of OKT3 anti-T cell induction and maintenance tacrolimus, mycophenolate mofetil, and methylprednisolone. Actuarial patient and graft survival have been 96% and 93%, respectively, in the controls and 91% and 91%, respectively, in the DBMC-infused recipients. Trough levels of tacrolimus were significantly lower in the DBMC-infused group. RESULTS: In PCR-Flow measurements, in peripheral blood up to 6 months postoperatively, there were higher levels of chimerism, i.e., in the total number of donor cells, as well as the donor CD3+ and CD34+ subsets in the LRD recipients administered DBMC infusions, compared with cadaver DBMC recipients, supporting the notion of a positive effect of histocompatibility on chimerism levels. In PCR-Flow measurements of recipient iliac crest bone marrow aspirates as in previous studies on peripheral blood, early acute rejection episodes (<1 month) were found to be associated with a later (6-14 months) decrease in donor cell lineage chimerism. However, a trend toward recovery of chimeric levels occurred by 21-28 months in a second iliac crest marrow aspirate 1 year after the first aspirate in the DBMC-infused recipients who experienced such early rejection episodes. This was in contrast to the controls in whom there were sustained low levels of iliac crest bone marrow chimerism at both the earlier and later intervals (i.e., no chimeric recovery), with 17/183 surviving controls progressing into chronic rejection. This has not yet been seen in the DBMC-infused group (0/54). In in vitro observations on cellular immune reactivity at 1 year postoperatively, decreased peripheral blood lymphocyte proliferative reactions were seen in response to phytohemagglutinin and Staph-A mitogens, as well as to cytomegalovirus and Epstein-Barr viral protein antigens in the DBMC-infused group versus the controls. Chronic immunosuppression did not seem to effect a vigorous in vitro inhibitory (regulatory) activity of bone marrow taken from these transplant recipients 2 years postoperatively in mixed lymphocyte culture and cell-mediated lympholysis reactions, using allogeneic responding cells from "normal" laboratory volunteers. Autologous peripheral blood lymphoproliferative responses to phytohemagglutinin and Staph-A mitogens, as well as to cytomegalovirus and Epstein-Barr virus protein antigens, were also regulated by either organ donor (non-immunosuppressed) bone marrow cells or by transplant recipient (immunosuppressed) bone marrow cells. What appeared to be disparate between the DBMC-infused and control groups (both immunosuppressed) was the trend for the (autologous) bone marrow suppressive effect on antiviral lymphoproliferative responses, to be stronger in the DBMC-infused group, who also had significantly (>one order of magnitude) higher levels of chimerism (P=0.01). CONCLUSIONS: It is concluded that the establishment of a chimeric state in DBMC-infused recipients, albeit of relatively low magnitude (approximately 1% at 2 years in recipient iliac crest bone marrow), has had a definite regulatory effect on immune responses. These results, therefore, add weight to the "causal" horn of the dilemma as to whether donor cell chimerism is a cause or an effect of