Nanostructures composed of liposomes and polydopamine (PDA) have demonstrated efficacy as carriers for delivering plasmids, effectively alleviating renal cell carcinoma. However, their role in acute kidney injury (AKI) remains unclear. This study aimed to investigate the effects of the plasmid-encoded lncRNA-OIP5-AS1@PDA nanoparticles (POP-NPs) on renal ischemia/reperfusion (RI/R) injury and explore the underlying mechanisms. RI/R or OGD/R models were established in mice and HK-2 cells, respectively. In vivo, vector or POP-NPs were administered (10 nmol, IV) 48 h after RI/R treatment. In the RI/R mouse model, the OIP5-AS1 and Nrf2/HO-1 expressions were down-regulated, while miR-410-3p expression was upregulated. POP-NPs treatment effectively reversed RI/R-induced renal tissue injury, restoring altered levels of blood urea nitrogen, creatinine, malondialdehyde, inflammatory factors (IL-8, IL-6, TNF-alpha), ROS, apoptosis, miR-410-3p, as well as the suppressed expression of SOD and Nrf2/HO-1 in the model mice. Similar results were obtained in cell models treated with POP-NPs. Additionally, miR-410-3p mimics could reverse the effects of POP-NPs on cellular models, partially counteracted by Nrf2 agonists. The binding relationship between OIP5-AS1 and miR-410-3p, alongside miR-410-3p and Nrf2, has been substantiated by dual-luciferase reporter and RNA pull-down assays. The study revealed that POP-NPs can attenuate RI/R-induced injury through miR-410-3p/Nrf2 axis. These findings lay the groundwork for future targeted therapeutic approaches utilizing nanoparticles for RI/R-induced AKI.

Objective:To observe the genetic characteristics of medullary sponge kidney (MSK) patients and explore the role of genetic factors in the occurrence of MSK.Methods:Genetic testing was performed on 7 patients with MSK stones using whole-genome sequencing technology, and the difference in the whole-genome between MSK patients and normal individuals was analyzed. The difference was more than 10 times, which was considered statistical significance. It may be significantly associated with disease occurrence. Gene ontology (GO) was used to analyze the relationship between the genotypes and MSK occurrence. The MSK-related pathogenetic factors in Chinese population were screened out.Results:Two kinds of genes with high frequency in MSK patients, including molecular function (GO: 0005488 Gene 1003, GO: 0003674 Gene 1138, GO: 0005515 Gene 795, GO: 0005509 Gene 86, GO: 0043167 Gene 470); biological process (GO: 0007275 Gene 440, GO: 0048856 Gene 463, GO: 0032502 Gene 487, GO: 0009653 Gene 232, GO: 0032501 Gene 566), may lead to predisposition to MSK.Conclusion:MSK patients have a genetic predisposition to stones.

This study explored the regulation of different perfusion methods on ischemia-reperfusion injury in donor kidneys. In this study, renal cortical/medullary tissue specimens were collected from porcine kidneys donors using different perfusion methods at various time points. Hematoxylin and eosin (H&E) staining was used to test the histological differences. Differentially expressed micro-ribonucleic acids (miRNAs) were identified by miRNA transcriptome sequencing. Reverse transcription-polymerase chain reaction (RT-PCR) tests were used to verify the changes in miRNAs in the kidney tissue taken from different perfusion groups. The related signaling pathways and the changes in the cell functions of different perfusion groups were analyzed by Kyoto Encyclopedia of Genes and Genomes (KEGG) /Gene Ontology (GO) bioinformatics analyses. The effects of miRNA overexpression on the metabolism and proliferation of HK2 cells were detected by ATP kit and MTT assay. The H&E staining results showed that there were essentially no differences in the tissue samples among different perfusion groups at and before 12 h compared with a control group. The quantitative PCR results revealed that there was essentially no change in the expression of ssc-miR-451, ssc-miR-1285, and ssc-miR-486 in the cis infusion or joint infusion kidney groups, and their expression was significantly down-regulated over time in the trans-infusion kidney group. The bioinformatics analysis showed that the cellular component, molecular function, and biological processes of the kidney tissue, which had been perfused using three methods, had been consistently affected. The most significant changes after perfusion occurred in the intracellular metabolism signaling pathways. Furthermore, the energy metabolism and proliferation of the HK2 cells were significantly inhibited after the overexpression of miR-451. Specific miRNA markers, such as miR-451, may play a negative regulatory role in cell metabolism following the perfusion of kidney transplants using different methods.

BACKGROUND:It is necessity to maintain donor kidneys at a low temperature for laparoscopic orthotopic kidney transplantation (LOKT). We recently designed a controllable double-cycle cryogenic device (DCD) with a safer and more effective cooling setting. This study aimed to evaluate the safety and efficacy of this device in a swine model.METHODS:A total of 20 pigs were procured for this study. We performed LOKT on 8 pigs using the controllable DCD for hypothermia, on another 8 pigs using the silicon tube cage (STC) for hypothermia, and on 4 pigs as the control group with no hypothermia measures (NH). The LOKTs were performed in autotransplantation mode in which the right kidney vein and artery were end-to-end anastomosed to the left kidney vein and artery in all three groups. The perioperative data, graft temperatures, and surgical complications were recorded, and histological examinations of kidney specimens were performed.RESULTS:The average surface temperature in the DCD group (5±3.5 °C) was significantly lower than that in the STC (10±5.5 °C) and NH (28±3.0 °C) groups. In the DCD and STC groups, the temperature between the cooling setting and the adjacent peritoneum was 30±3.0 and 12±5.0 °C, respectively. All pigs survived for 7 days in the DCD group. In the STC group, 2 pigs died from liver lesions and other causes. A single pig had diabetes insipidus. No pigs survived for 7 days in the NH group. The specimens from pigs immediately after revascularization and from the surviving pigs on day 7 following transplantation showed that the morphology of the glomerular and renal tubules was largely normal in the DCD and STC groups. However, in the NH group, there was minimal interstitial and tubular oedema, and endothelial cell swelling occurred in some specimens immediately after revascularization. Pathological examination of the harvested graft specimens showed severe acute tubular necrosis in the NH group.CONCLUSIONS:The newly designed controllable DCD can achieve the goal of cooling the kidney and warming the patient and may be a reliable, effective, inexpensive, and practical hypothermic maintenance system for LOKT in swine.

目的 探究膀胱癌细胞Bloom综合征解旋酶(BLM)表达水平及其临床意义.方法 在GEPIA数据库检索BLM在膀胱癌中的表达水平,并在膀胱癌细胞系T24和人正常膀胱上皮永生化细胞SV-HUC-1中检测BLM表达水平;转染T24细胞sh-NC和sh-BLM,未转染细胞作为对照;检测T24细胞增殖和凋亡水平.结果 与非BLCA组比较,膀胱癌组织和细胞系T24细胞中BLM表达水平均上调(P<0.01).与对照组比较,T24+sh-BLM组T24细胞BLM mRNA表达水平降低,增殖能力下降,凋亡水平升高(P<0.01).结论 在膀胱癌中BLM基因表达升高,与膀胱癌疾病进程相关,敲低其表达可抑制细胞增殖、促进凋亡.

Introduction: Laparoscopic renal cyst decortication is currently the best choice for the treatment of simple renal cysts and is widely used in clinical practice Aim: To investigate the safety and clinical efficacy of two-trocar mini-laparoscopic decortication of adult renal cysts. Material and methods: A total of 90 patients were enrolled in the study and randomly divided into two groups: a two-trocar mini-laparoscopic treatment group (M group) and a three-trocar standard laparoscopic treatment group (S group), with 45 patients in each group. Results: The average length of hospital stay was shorter, and the demand for postoperative analgesics was less in the M group than in the S group (p < 0.05). The proportion of "very satisfied" patients in the patient physical recovery satisfaction survey was significantly higher in the M group than in the S group (p < 0.05). Of the 45 patients in the M group, 40 successfully underwent surgery. In 3 patients, the two-trocar procedure was converted to a three-trocar procedure due to difficulty in separating perirenal adhesion for visualization. Mini-laparoscopic surgery was converted to classic laparoscopic surgery in 2 patients. In the S group, 44 patients successfully underwent the renal cyst decortication procedure. One patient underwent partial renal resection due to an intraoperative diagnosis of multilocular cystic renal cell carcinoma. Postoperative urine leakage was reported in 3 patients in the M group and two in the S group. Conclusions: Two-trocar mini-laparoscopic treatment of renal cysts is as safe and effective as traditional laparoscopy but is associated with less cosmetic damage, leading to a better physical appearance.

OBJECTIVE:The present study aimed to observe and discuss the effectiveness and safety of the UreTron single-probe ultrasonic intracorporeal lithotripter in ureteroscopic lithotripsy. METHODS:The clinical data of patients with unilateral solitary ureteral calculi treated with ureteroscopic lithotripsy who were hospitalized at the Department of Urology (West District) of Beijing Chaoyang Hospital between March 2016 and August 2020 were selected for retrospective analysis. The patients were divided into the UreTron group (group U) and holmium laser group (group H) according to the lithotripsy method adopted. The operation duration, length of hospital stay, stone clearance rate, proportion of patients requiring flexible ureteroscopy-assisted lithotripsy, and complications were compared between the groups. RESULTS:There was no statistical difference between the groups in terms of the general characteristics, operation duration, or length of hospital stay (P > 0.05). Regarding the stone clearance rate (group U=93.5%; group H=75%), proportion of patients requiring flexible ureteroscopy-assisted lithotripsy (group U=6.5%; group H=27.8%), and incidence of surgical complications (group U=1 case; group H=9 cases), group U was superior to group H, and the differences between the groups were statistically significant (P < 0.05). However, the differences in other complications (cardiocerebral complications and lower extremity thrombosis) were not statistically significant between the groups (P > 0.05). CONCLUSION:The UreTron system is a new lithotripsy apparatus that is safe and effective for ureteroscopic lithotripsy and has certain advantages in terms of the stone clearance rate, proportion of patients requiring flexible ureteroscopy-assisted lithotripsy, and surgical complications, making it worthy of clinical application.

BACKGROUND:Bladder surgery has a negative impact on patients' mental health, sleep quality. Conventional nursing interventions failed to meet the clinical needs. Therefore, this parallel-group RCT was performed to assess the effect of individualized psychological intervention on patients' negative emotions and sleep quality after bladder cancer surgery. METHODS:Patients with bladder cancer admitted to our hospital (from September 2018 to October 2020) and underwent surgical treatment were selected as the research objects. They were randomly allocated to a parallel control group or observation group based on a computer-generated random numbers table. Because our study included behavioral intervention, blinding was not possible for participants and care givers. The control group received conventional nursing care, and the observation group received strengthened individualized psychological intervention under the nursing measures of the control group. Sleep quality, anxiety, depression, nursing compliance, and the occurrence of bladder spasm were compared between the two groups. RESULTS:Seventy-eight eligible patients were included and randomly divided in two groups (n=39 for each group). The intervention procedure was completed without losses and exclusions of patients after randomization. Before the intervention, the Pittsburgh Sleep Quality Index Scale and the anxiety and depression scores were comparable between the two groups (P>0.05). After the intervention, the data of the two groups were significantly improved. The sleep quality, sleep time, sleep efficiency, the time to fall asleep, hypnotic drugs, sleep disorders, daytime dysfunction, anxiety score, and depression score of the observation group were lower than those of the control group, with significant differences (P<0.05). The total nursing compliance rate of the observation group reached 100.00%, which was higher than the control group. The difference between the groups was significant (P<0.05). There was no significant difference in the incidence of bladder spasm between the two groups (P>0.05). CONCLUSIONS:Individualized psychological intervention applied to bladder cancer surgery can effectively improve patients' negative emotions and improve their sleep quality. TRIAL REGISTRATION:Chinese Clinical Trial Registry ChiCTR2100046468.

To report on the pioneering clinical experiences of six cases of extraperitoneal laparoscopic kidney transplantation in China. For the first time in clinical practice, a customised, controllable double-circulation cooling device was used to protect the transplanted kidney. Of the six patients, two underwent an allograft renal transplantation because they had been diagnosed with uraemia and were on maintenance haemodialysis. The other four patients underwent kidney autotransplantation because of a central renal tumour. The extraperitoneal laparoscopic kidney transplantations were successfully completed between 2017 and 2018. The operative time for the two patients undergoing the allograft transplantation was 3–3.5 h. The time for venous anastomosis was approximately 53–65 min, and the time for arterial anastomosis was approximately 25–30 min. The creatinine level was 90–80 μmol/L after surgery. The operative time of the four patients who underwent autotransplantation was 9.4–17.5 h. The times of venous and arterial anastomosis were 58–90 min and 35–48 min, respectively. The follow-up B-mode ultrasound after surgery showed good blood supply in the spared nephron. A renal graft was removed from one patient 6 months after surgery because of renal atrophy and dysfunction caused by poor blood supply. Five patients (two undergoing allografting and three undergoing autografting) completed the 12-month follow-up, and their renal graft function was good. Extraperitoneal laparoscopic kidney transplantation, either allograft or autologous transplantation, is a safe and feasible procedure with a good chance of survival for the transplanted kidney. A customised cooling device is effective and practical during laparoscopic kidney transplantation.

Background: Ischemia–reperfusion injury (IRI) is one of the main causes of acute kidney injury. Our previous results have shown that anti-oxidative stress decreased in the renal IRI model. This study aimed to investigate the effect of Lactobacillus acidophilus ATCC 4356 on oxidative stress, inflammation, and intestinal flora in renal IRI. Methods: The model of renal IRI was established by cross-clamping the renal pedicle with non-traumatic vascular forceps. H&E staining was applied to observe the damage of kidney tissue in each group. The concentrations of serum blood urea nitrogen (BUN), creatinine (Cre), superoxide dismutase (SOD), glutathione (GSH), and malondialdehyde (MDA) were detected by biochemical kit. ELISA measured the concentrations of interleukin (IL)-1β, IL-8, IL-4, and IL-10. qRT-PCR was performed to detect molecular expressions of ATCC 4356, oxidative stress-related factors [nuclear factor-related factor 2 (Nrf2), heme oxygenase 1 (HO-1)], inflammatory factors [tumor necrosis factor (TNF)-α, IL-1β, IL-8, interferon (IFN)-γ, IL-4, IL-10], and apoptosis-related factors [caspase 3, Bax, Bcl2, high-mobility group box protein 1 (HMGB1)]. Except for ATCC 4356, the protein expression of the above indicators was detected by Western blot. The apoptosis level of renal tissue cells was detected by TdT-mediated dUTP nick end labeling (TUNEL). 16S rDNA gene sequencing was used to detect the changes of microbial species in the contents of the duodenum and screen out the differentially expressed flora. Results: Both the glomeruli and renal tubules of ischemia/reperfusion (I/R) mice were severely damaged. H&E result displayed that L. acidophilus ATCC 4356 attenuated the infiltration of inflammatory cells caused by I/R. ATCC 4356 reduced the high expression of BUN and Cre in I/R mice with a dose effect. It also reduced the high expression of MDA, TNF-α, IL-1β, IL-8, IFN-γ, caspase 3, Bax, and HMGB1 in I/R mice, while it increased the low expression of SOD, GSH, Nrf2, HO-1, IL-4, IL-10, and Bcl2 in I/R mice. ATCC 4356 inhibited the high level of apoptosis in the kidney tissue of I/R mice. In IRI mice, the top 3 different gut microbiota were Helicobacter, cultivated_bacterium , and k__Bacteria_ASV_3 compared with sham mice. Oral L. acidophilus ATCC 4356 reversed this change. Conclusion: L. acidophilus ATCC 4356 attenuated renal IRI through anti-oxidative stress and anti-inflammatory response and improved the intestinal microbial distribution.

Objective: To investigate the safety and efficacy of a vascular prop device for laparoscopic orthotopic kidney transplantation (LOKT) in swine. Material and Methods: Twenty swine were randomly divided into two groups. A vascular prop device was used in the observation (VP) group, and the vein beltization technique was used in the control (VB) group. The right kidney, as a donor graft, was laparoscopically transplanted to the location of the left kidney after a left nephrectomy. Data on the operative time, venous anastomotic time, vein stenosis, etc., and the survival of the swine in the two groups were recorded. Results: The mean transplant operative time, the mean cold ischemia time, and the venous anastomotic times in the VP group were significantly shorter than those in the VB group. Seven swine in the VP group and three swine in the VB group survived for 7 days. Autopsy results showed the occurrence of one artery stenosis and one vein stenosis in the VP group and one artery stenosis and five vein stenoses in the VB group. The median survival time was 6.25 days for the swine in the VP group and 4.40 days for those in the VB group. Conclusions: The vascular prop device is safe and feasible for LOKT in swine and may accelerate venous anastomosis and ensure the quality of venous anastomotic stoma.

前列腺癌一直是男性健康的重要威胁，在西方国家一直是男性发病率第一，死亡率第二的肿瘤。近年来，随着经济发展和饮食结构改变，我国前列腺癌的发病率也在逐年升高。虽然没有明确的直接致癌因素，但是前列腺癌和其他肿瘤一样，它的发生受环境和生活习惯等多因素共同影响，并且存在家族遗传倾向。

BACKGROUND: Multidrug- and extensively drug-resistant tuberculosis (MDR/XDR-TB) continues to be a challenge in China. Bedaquiline (BDQ) is associated with accelerated sputum culture conversion and favourable treatment outcomes when added to a preferred background regimen. This post-hoc study aimed to assess the outcomes of BDQ treatment in Chinese patients with MDR/XDR-TB.METHODS: Data from 51 Chinese patients who participated in a global Phase 2, open-label, single-arm study (TMC207-C209) were analysed for effectiveness and safety of the BDQ-containing regimen.RESULTS: During the 24-week BDQ treatment, adverse events (AEs) occurred in 48 patients (94.1%), with the most common AE being hyperuricemia. Drug-induced liver injury (DILI) was reported in 13 patients (25.5%); serious DILI was reported in one patient (2.0%). Seven (13.7%) AEs were considered to be possibly related to BDQ by the investigators. Only one Grade 1 QTc prolongation was reported; no QTcF >500 ms was reported. One death occurred after BDQ treatment due to progressive TB. The median time to sputum culture conversion was 85 days based on the 24-week data. The sputum culture conversion rate was 82% at 24 weeks and 78% at 120 weeks; 66% of patients achieved a cure.CONCLUSIONS: BDQ was well-tolerated and effective for treating MDR-TB among Chinese patients.

Introduction: This study aimed to investigate the safety and efficacy of mini-laparoscopy for renal cyst unroofing. Material and methods: Eighty-six patients for treatment of renal cysts that met the selection criteria were included in this study. They were divided into two groups. Forty-five patients underwent cyst unroofing via mini-laparoscopy (Group M), and 43 patients underwent cyst unroofing via standard laparoscopy (Group S). There were no differences between the two groups in terms of sex, age, body mass index or clinical data. Data from the groups were recorded and analyzed. Results: The average hospital stays were shorter (p = .039) and postoperative painkiller demand was lower (p = .031) in Group M than in Group S. Forty-one out of 45 procedures in Group M were successful, and all 43 cases in Group S were successfully. With a follow-up period of 0.5 to 5.5 years, there was no significant difference in recovery rate (p = .213). Questionnaires showed that patients in Group M were significantly more satisfied with their cosmetic results than were patients in Group S (p = .041). Conclusion: Our findings suggest that renal cyst decortications with mini-laparoscopic instruments are as safe and effective as procedures using standard laparoscopic instruments. Cosmetically, the results are better with mini-laparoscopy than with standard laparoscopic unroofing.

目的 探讨迷你腹腔镜治疗隐睾合并腹股沟疝的安全性和有效性.方法 收集2010年10月至2018年10月于河北省肃宁县人民医院泌尿外科收治的21例隐睾合并同侧腹股沟疝患者.应用迷你腹腔镜(5.0 mm直径高清晰腹腔镜,2.8 mm的分离钳,持针器等)行微创治疗.对本研究患者进行回顾性分析.结果 本组患者平均手术时间(95.0±12.3)min.因隐睾、精索发育不良,行阴睾切除疝囊高于结扎2例.6例患儿因分离精索、输精管时后腹膜缺损,内环口后腹膜未关闭.3例成人患者完成隐睾松解固定术后,内环口过大,遂将5.0 mm Trocar更换为10 mm Trocar.置入补片,缝合后腹膜.21例患者术后无阴囊血肿、阴囊感染、切口感染等并发症.术后无慢性腹股沟痛.2例术后分别为5.5年和1.7年一直睾丸较小,超声示睾丸萎缩.随访(6.6±3.4)年(0.3～8.7年),无疝复发.结论 应用迷你腹腔镜治疗隐睾合并腹股沟疝是安全可靠的,损伤小、恢复快、并发症少.

Abstract Background Percutaneous nephrolithotomy (PCNL) is a safe and efficient treatment for intro-renal diseases, most of which are calculus disease. In this study, we carried out percutaneous endoscopic nephron-sparing ablation for renal carcinoma in carefully selected patients. Our aim was to evaluate whether percutaneous endoscopic nephron-sparing operation was feasible for patients with renal cell carcinoma.Methods A total of 15 patients with renal pelvis carcinoma were treated with laser evaporation under percutaneous endoscopy between January 2015 and September 2019 ( group I ). Another 13 patients who received standard radical nephroureterectomy were recruited as the control group (group II). We recorded demographic data of the patients, the indication for surgery, tumor pathological grade, size and side of tumor, and the intraoperative and postoperative outcome, including the duration of surgery, length of hospital stay, and complication rate, as well as progression-free survival (PFS).Results In both groups, all of the patients received flexible ureteroscopy. In group I, 14 patients had transitional renal cell carcinoma (UCC), four had pathological grade I, nine had grade II, and one had hemangiopericytoma. In group II, all patients had UCC, five had pathological grade I, and eight had grade II. In group I, the mean operation time was 118 min (65–236 min), the mean blood loss was 110 ml (55–220 ml), and the mean hospital stay was 9 days (7–12 days). During follow-up, two patients died and two had recurrence; among them, one had systematic bone metastasis. The PFS rate was 66.7% (10/15). In group II, the mean operation time was 265 min (185–436 min), the mean blood loss was 133 ml (85–240 ml), and the mean hospital stay was 13 days (9–16 days). During the follow-up, two patients died and there was no local or systematic metastasis. The PFS rate was 84.6% (11/13). There was no significant difference in blood loss between the groups. However, the operation time and mean hospital stay were significantly shorter in group I compared with that in group II ( P < 0.05). But the PFS rate was significantly higher in group II than in group I (P < 0.05).Conclusions This study shows that laser evaporation under percutaneous endoscopy for renal pelvis carcinoma is a safe, effective, and technically feasible procedure for treating benign and malignant renal pelvis carcinoma.

BACKGROUND This study investigated the safety and efficacy of a new cooling device for use in minimal-incision kidney transplantation (MIKT). MATERIAL AND METHODS From June 2016 to December 2021, 9 patients underwent MIKT surgery in our hospitals using the new cooling device to maintain hypothermia. We recorded and analyzed information on the etiology, comorbid status, ongoing renal replacement assessment, BMI, HLA mismatching sites of donors and recipients, and perioperative and postoperative clinical data for recipients. RESULTS Kidney transplantation was successfully performed in all patients. The kidney surface temperature measurement results showed that the intraoperative renal anterior and posterior surface temperatures were stable at approximately 3.8±1.2°C and 5.2±1.3°C, respectively, during ice-water circulation. The mean operation time was 112±15 min, the artery anastomosis time was 16±6.0 min, and the vein anastomosis time was 14±4.5 min. All recipients recovered uneventfully. The patients were followed up for 6-30 months. Urinary and vascular complications were not found in any recipients. CONCLUSIONS The new cooling device can facilitate MIKT. It is safe and feasible to carry out MIKT using the new cooling device, which can reduce surgical trauma and improve the quality of vascular anastomosis with satisfactory cosmetic results.

[目的]总结腹腔镜自体肾移植手术治疗中央型肾癌的护理措施.[方法]对2例腹腔镜自体肾移植病人进行术前准备、术中配合、术后病情观察、并发症处理的护理总结,出院后随诊指导的观察.[结果]2例腹腔镜自体肾移植病人移植成功,出院后9个月随诊各项观察指标均在正常范围,未见有明显肿瘤复发或者移植肾功能失功情况,出院后随诊的重要指标肾功能、移植肾血流指数均正常.[结论]腹腔镜自体肾移植手术治疗中央型肾癌,在根治肿瘤的同时,能最大程度保护肾单位,同时还能最大限度降低对病人的创伤,并通过专科护理、全方位知识掌握、充足的术前准备、专业的术中及术后护理等,为手术成功奠定基础、利于病情改善.

To the Editor: Renal carcinoma is one of the most commonly encountered urological malignant carcinomas, accounting for 2% to 3% of all adult malignant carcinomas; mortality is over 40%.[1] With recent developments in medical technology, surgical, and auxiliary treatment of renal carcinoma has improved greatly. Once considered as a high-risk group, patients with renal carcinoma and inferior vena caval tumor thrombosis can receive ideal treatment now. We performed pure laparoscopic radical nephrectomy and inferior vena caval tumor thrombus removal in five patients, two men and three women aged 39 to 71 years (mean: 59 years). Two patients had frank hematuria, two had flank pain, and one was asymptomatic. Three patients were affected in the left kidney and two in the right kidney. Three had grade I tumor thrombosis, and two had grade II. Tumor length ranged from 2.0 to 4.1 cm in the grade II group, and tumor size ranged from 3.8 to 11.2 cm for all patients. One patient had renal hilar lymph node metastasis and another had bone metastasis. All patients provided the appropriate consent forms. All five patients underwent successful pure laparoscopic radical nephrectomy and inferior vena caval thrombus removal. Two patients with right kidney carcinoma had grade I thrombosis, and we chose a right retroperitoneal incision. We first transected the renal artery and then sutured the inferior vena cava. In the three patients with left kidney carcinoma, one patient had a grade I thrombus, and we chose a right-sided 30° oblique position and a transperitoneal incision to isolate the kidney. After ligating the renal artery, we changed the patient to a left-sided 30° oblique position. We opened the right paracolic sulcus, and when we reached the entries of the left renal vein and inferior vena cava, we occluded the vena cava laterally at its junction with the renal vein. The lateral vena cava was sutured after removing the kidney and thrombus. The remaining two patients had grade II thrombi, and underwent similar procedures. After isolating the vena cava, we temporarily occluded the right renal artery and occluded the vena cava proximal and distal to the thrombus. We then opened the vena cava and removed the thrombus and sutured the vena cava [Supplementary video, http://links.lww.com/CM9/A90]. For the patient with left kidney carcinoma and grade I thrombosis, we chose a right transperitoneal incision with a right-sided 30° oblique position to isolate the kidney before ligating the renal artery. The patient was then changed to a left-sided 30° oblique position. We opened the right paracolic sulcus to expose and isolate the junction of the left renal vein and inferior vena cava, then occluded the inferior vena cava laterally at the entrance of the renal vein and removed the kidney and tumor thrombus followed by suturing the inferior vena cava. For the two patients with grade I thrombosis, the initial procedure was similar. After isolating the inferior vena cava, we temporarily occluded the right renal artery and the vena cava proximal and distal to the thrombus. We then opened the vena cava wall to remove the thrombus, and sutured the vena cava laparoscopically. Pre- and post-operative creatinine levels were recorded and compared [Figure 1].Figure 1: Plain computed tomography showing left kidney carcinoma with inferior vena caval thrombosis (A). The tumor and thrombus (coronal section; B). Isolating the vena cava and exposing the vena caval wall containing the thrombus (C). Removing the thrombus (D).Surgery in all five patients was completed successfully with no thrombus lost as an embolus. Mean operation time was 360 ± 45 min, and mean intra-operative blood loss volume was 500 ± 180 mL. One patient received an infusion of an 800 mL suspension of red blood cells. Mean hospitalization duration was 11 ± 3 days. Histopathology confirmed transitional cell carcinoma, Fuhrman grade II, in four patients; one patient had sarcomatoid carcinoma. All five patients received post-operative targeted therapy; four received sorafenib, and one received sunitinib. Patients were followed for 2 to 18 months, and their median survival time was 11 months. There was no significant difference in blood creatinine level pre- and post-operatively (72 ± 11 mg/dL vs. 84 ± 7 mg/dL, P = 0.15). Locally-advanced renal cell carcinoma often invades the venous system, which has been reported in 4% to 10% of patients with renal carcinoma, usually affecting either the renal vein or inferior vena cava.[2] For patients with venous system tumor thrombosis, radical nephrectomy with vena caval tumor thrombus removal is the only curative treatment. Cost et al[3] first reported pure laparoscopic radical nephrectomy and inferior vena caval tumor thrombus removal. A retrospective analysis of laparoscopic radical nephrectomy with removing the inferior vena caval thrombus revealed that most procedures involved right kidney carcinoma. This right-sided predominance may be because the right renal vein is relatively short and closely adjacent to the inferior vena cava. A second reason is that, for right kidney carcinoma, the branches of the reflux veins, that is, gonadal vein, adrenal vein, and lumbar veins, provide sufficient compensatory drainage, which allows removal of the invaded part of the vena cava when necessary. For left kidney carcinoma with inferior vena caval thrombosis, most thrombi are grade I, usually lower in grade than for right kidney carcinoma, but if tumor invades the vena cava, the tumor is usually more aggressive, which makes the procedure more challenging. Third, there are not enough reflux veins for the right renal veins, and when removing invaded partial vena cava, venous bypass or autologous kidney transplantation is required. These differences make it relatively easier to perform right kidney carcinoma with vena caval thrombus removal. With left renal carcinoma, complicated procedures are necessary for the renal vein and inferior vena cava, which increase the difficulty. More importantly, for procedures involving right kidney carcinoma, it is possible to transect and reconstruct the inferior vena cava, and there is no need to preserve the left renal vein, considering the sufficient compensatory drainage. In contrast, damaging the right renal vein must be avoided with left kidney tumors. Pre-operative targeted therapy may lower the tumor thrombosis stage, which in turn reduces surgical difficulty.[4] However, a recent clinical study reported that lower tumor thrombosis stage was seen in only 12% of patients receiving pre-operative targeted therapy, and the surgical plan was implemented successfully in only 4% of patients.[5] Furthermore, some urologists reported that targeted therapy could increase both adhesions around the lesion and intra-operative bleeding, increasing the surgical difficulty. One of our patients with inferior vena caval tumor thrombosis and remote vein thrombosis received a temporary filter. The remote vein thrombosis resolved 3 days after post-operative anti-coagulation therapy, and the filter was removed. Our recommendation for placing a filter is to make this decision on a per-patient basis. For left kidney carcinoma with tumor thrombosis, some centers selected a retroperitoneal route to treat the renal vessel first, and a peritoneal route to address the inferior vena cava, which provided satisfactory results. Our results show that although pure laparoscopic radical nephrectomy and inferior vena caval tumor thrombus removal is still one of the most challenging procedures in urology, the procedure is safe and feasible. However, surgeons must perform a thorough and careful pre-operative assessment and have laparoscopic expertise, especially in vascular suturing techniques. Conflicts of interest None.