Effect of adherent perinephric fat on outcomes of nephron-sparing treatment of renal cell cancer

Introduction. Nephrometric scales have been developed to determine the appropriate surgical tactics and to predict intraoperative values more accurately, considering the characteristics of the renal tumour. However, there is a need to assess the perinephric fat. The Mayo Adhesive Probability (MAP) scale aims to identify adherent perinephric fat (APF) or 'complex' paranephric fat preoperatively.Objective. To evaluate the effect of APF on intraoperative and functional outcomes of patients with renal cell cancer (RCC) who underwent laparoscopic partial nephrectomy.Materials & methods. We analysed 118 patients with localised RCC who underwent laparoscopic partial nephrectomy. At the preoperative stage, according to the results of contract-enhanced msCT, the presence of APF was assessed using the MAP scale. At the same time, the thickness of the posterior perinephric fat was measured and the grade of its twisting was assessed. As a result, the patients were divided into two groups: group 1 MAP 0 – 2 pts (no APF) 34 patients and group 2 MAP 3 – 5 pts (presence of APF) 84 patients. In each group, the following indicators were assessed: stage according to the TNM classification, mean age and BMI, average nephrometry score according to the R.E.N.A.L. system, glomerular filtration rate (GFR).Results. The median surgery time for group 1 patients was 115.0 [92.5; 142.5] min, for group 2 — 130.0 [101.3; 180.0] min. The median warm ischemia time in patients in group 1 was 15 [0; 20] min, in group 2 — 12 [0; 18] min. The median blood loss in the groups 1 and 2 was 50 [15; 100] and 50 [0; 100] ml, respectively. The mean GFR on the first day after surgery was 63.34 ± 18.40 ml/min/1.73 m2 in group 1 and 55.09 ± 16.01 ml/min/1.73 m2 in group 2. Openings of the pyelocalyceal system were observed in 8 (23.53%) and 23 (27.38%) patients in groups 1 and 2, respectively. A positive surgical margin was detected one patient in group 1 and two in group 2. Early postoperative complications in group 1 were four patients and group 2 — 15 patients.Conclusion. The presence of APF and its severity can be effectively assessed using the MAP score, which is promising, but is limited only to the prognostic of APF without correlation with nephrometric scales that assess tumour anatomy parameters. However, the issue of developing a unified assessment system that includes APF and kidney morphometry is currently open, and the definition of APF is still subjective and requires an objective analysis to obtain more accurate outcomes

Факторы риска и методы профилактики лимфогенных осложнений при онкоурологических операциях на органах малого таза (систематический обзор)

Radical prostatectomy and cystectomy with pelvic lymphatic dissection are the most common operations in oncourology. Development of lymphatic complications, such as lymphocele, lymphorrhea and lymphedema, often complicates their implementation. However, not all lymphatic complications manifest themselves clinically and require surgical treatment. There are many risk factors and methods for preventing lymphogenic complications during oncourological operations in the pelvic area. In this article, we will review potential provocative factors that should be considered when performing oncourological interventions in the pelvis, as well as methods for their prevention, which can minimize the lymphogenic complications.Радикальная простатэктомия и цистэктомия с тазовой лимфодиссекцией являются наиболее распространенными операциями в онкоурологии, и развитие лимфатических осложнений, таких как лимфоцеле, лимфорея и лимфедема, часто осложняет их выполнение. Однако не все лимфатические осложнения проявляются клинически и требуют хирургического вмешательства. Существует множество факторов риска и методов профилактики лимфогенных осложнений при онкоурологических операциях на органах малого таза. В настоящем обзоре рассмотрены потенциально провоцирующие факторы, которые следует учитывать при проведении онкоурологических вмешательств в малом тазу, а также методы их профилактики, позволяющие свести к минимуму образование лимфогенных осложнений

Стриктуры уретры после трансуретральных вмешательств: особенности лечения и гистологические аспекты

Introduction. The development of upper and lower urinary endoscopic surgery has brought about an increase in the number of urethral strictures after transurethral procedures.Material and methods. A retrospective analysis was performed involving the treatment results of 72 patients with urethral strictures after transurethral surgery in 2011-2016. All the patients underwent standard examination, including US, residual urine analysis, uroflowmetry, retrograde and micturating urethrography, IPSS and QoL questioning and general clinical tests.Results and discussion. The median of observation comprised 28 months. Bulbous urethra appeared to be the most frequent localisation of urethral strictures (87.5 %). The median stricture length was 2 cm with the mean maximum urine flow rate equal to 5.9 ± 2.7 mL/s. The median IPSS score counted 25 points. The type and number of surgical procedures were as follows: internal optic urethrotonomy (29), anastomotic urethroplasty (18), single-stage skin flap urethroplasty (3), single-stage urethroplasty using buccal mucosa graft (17), multiple-stage urethroplasty using buccal mucosa graft (1), meatotomy (1), single-stage navicular fossa urethroplasty using buccal mucosa graft (1). Internal optic urethrotonomy was to be effective in 52 % cases, while other surgical procedures showed 89 % effectiveness. The pathomorpho-logic studies revealed severe inflammation without signs of stroma fibrosis within urethral strictures.Conclusion. Transurethral endoscopic procedures appear to be the main causative factor (in 54 % cases) for iatrogenic urethral strictures.Введение. Развитие эндоскопической хирургии верхних и нижних мочевыводящих путей привело к увеличению количества стриктур уретры после трансуретральных вмешательств.Материалы и методы. Проведен ретроспективный анализ результатов лечения 72 пациентов со стриктурой уретры после трансуретральных вмешательств, проходивших лечение в период 2011-2016 гг. Пациентам проводилось комплексное рутинное обследование, включающее в себя ультразвуковую диагностику, урофлоуметрию, оценку остаточной мочи, ретроградную и микционную уретрографии, анкетирование по опросникам IPSS и шкале QoL, общеклинические анализы.Результаты и обсуждение. Медиана наблюдения составила 28 месяцев. Наиболее частая локализация: бульбоз-ный отдел — 87,5 %. Медиана протяженности стриктуры составила 2 см. Среднее значение показателя максимальной скорости мочеиспускания составило 5,9 ± 2,7 мл/с. Медиана суммы баллов шкалы IPSS — 25. Вид (количество) операций при стриктурах уретры после трансуретральных вмешательств: внутренняя оптическая уретротомия (29), анастомотическая уретропластика (18), одноэтапная пластика кожным лоскутом (3), одноэтапная уретропластика буккальным графтом (17), многоэтапная уретропластика буккальным графтом (1), ме-атотомия (3), одноэтапная пластика ладьевидной ямки буккальным графтом (1). Эффективность ВОУТ составила 52 %, эффективность различных видов уретропластики — от 89 %. Патоморфологические исследования показали наличие выраженного воспаления без признаков фиброза стромы в зоне стриктуры уретры.Заключение. Трансуретральные оперативные вмешательства являются ведущим этиологическим фактором образования ятрогенных стриктур уретры, достигая 54 %

Сравнение периоперационных и ранних функциональных результатов лапароскопической резекции почки с опухолью при стадии cT1aN0M0 и cT1b-T2aN0M0

Background. Since partial nephrectomy and radical nephrectomy demonstrate comparable oncological safety, nephronsparing surgery is the method of choice in patients with stage T1-T2aN0M0 renal cell carcinoma.Objective: to compare the main perioperative parameters and short-term functional outcomes of treatment for localized stage cT1aN0M0 and cT1b-T2aN0M0 renal cell carcinoma.Materials and methods. A total of 148 laparoscopic partial nephrectomies were performed at N.I. Pirogov City Clinical Hospital No. 1, N.I. Pirogov Russian National Research Medical University between 2016 and 2020. Study participants were divided into two groups. Group 1 included patients with stage cT1aN0M0 tumors (n = 89; 60.1 %), whereas group 2 comprised patients with stage T1b-T2aN0M0 tumors (n = 59; 39.9 %).Results. The duration of surgery was 120 min (range: 90-150 min) in group 1 and 145 min (range: 120-170 min) in group 2 (p = 0.001). The median time of warm ischemia was 13 min (range: 7-17) and 15 min (range: 12-19 min) in groups 1 and 2, respectively (p = 0.002). Seven individuals from group 1 (7.9 %) and 12 individuals from group 2 (22.3 %) had their pelvicalyceal system lanced. The median glomerular filtration rate calculated using the MDRD (Modification of Diet in Renal Disease) formula was 56.4 mL/min/1.73 m2 in group 1 and 54.3 mL/min/1.73 m2 in group 2 (p = 0.252). Three patients in group 1 (3.4 %) had positive resection margin. The median follow-up time was 21 months.Conclusion. Nephron-sparing surgeries are an acceptable option for patients with stage cT1b-T2aN0M0 tumors in terms of their oncological and functional safety. Tumors exceeding 4 cm were associated with an increased risk of disease progression.Введение. С учетом сопоставимой онкологической безопасности резекции почки и радикальной нефрэктомии органосохраняющее лечение является методом выбора у пациентов с почечно-клеточным раком стадии T1-T2aN0M0.Цель исследования - сравнение основных периоперационных показателей, а также ранних функциональных результатов лечения локализованного рака почки клинических стадий сТ1аN0M0 и сT1b-T2аN0M0.Материалы и методы. С 2016 г. по октябрь 2020 г. включительно в университетской клинике урологии РНИМУ им. Н.И. Пирогова на базе Городской клинической больницы № 1 им. Н.И. Пирогова было выполнено 148 лапароскопических резекций почки. Пациенты были разделены на 2 группы: 1-я - 89 (60,1 %) пациентов со стадией рака сТ1аN0M0; 2-я - 59 (39,9 %) пациентов со стадией сT1b-T2аN0M0.Результаты. Продолжительность операции у пациентов 1-й группы составила 120 (90-150) мин, у пациентов 2-й группы - 145 (120-170) мин (p = 0,001). Медиана времени тепловой ишемии в 1-й и 2-й группах составила 13 (7-17) и 15 (12-19) мин (p = 0,002), вскрытие чашечно-лоханочной системы наблюдалось в 8 (8,9 %) и 14 (23,7 %) случаях соответственно. Осложнения развились у 7 (7,9 %) пациентов 1-й группы и у 12 (22,3 %) пациентов 2-й группы. Медиана скорости клубочковой фильтрации, рассчитанная по формуле MDRD (Modification of Diet in Renal Disease), в 1-й группе составила 56,4 мл/мин/1,73 м2, во 2-й - 54,3 мл/мин/1,73 м2 (p = 0,252). Положительный хирургический край наблюдался в 3 (3,4 %) случаях в 1-й группе. Медиана времени наблюдения составила 21 мес.Заключение. Выполнение резекции почки у пациентов со стадией почечно-клеточного рака сT1b-T2аN0M0 является допустимым с точки зрения онкологической и функциональной безопасности. Размер опухоли, превышающий 4 см, сопряжен с риском прогрессирования заболевания

Оценка функциональных результатов и безопасности раннего удаления уретрального катетера после лапароскопической радикальной простатэктомии

Background. Currently, there is no single point of view on the timing of safe removal of the urethral catheter in patients who have undergone laparoscopic radical prostatectomy.Objective of the study: to evaluate the safety and functional results of early removal of the urethral catheter after laparoscopic radical prostatectomy.Materials and methods. In the period from January 2020 until April 2021, the study included 100 patients with a diagnosis of prostate cancer who underwent laparoscopic radical prostatectomy by one surgeon. Patients were divided into 2 groups. Group A (n = 50) included patients with the urethral catheter removed on the second day after surgery. Group B (n = 50) – the control group – included patients with standard catheter removal (14 days).Results. According to the results of cystography, in group A extravasation of a contrast agent from the zone of urethrovesical anastomosis was determined in 3 (6 %) cases. Seven (14 %) patients developed acute urinary retention after the removal of the urethral catheter. Among 2 patients acute urinary retention occurred immediately after catheter removal. In 5 cases acute urinary retention developed 2–7 days after catheter removal. These patients underwent repeated catheterization for a period of 2–3 days. In our study, removal of the urethral catheter on the second day increased the dynamic of restoring urinary continence in the postoperative period. The frequency of complete recovery of urinary continence (0–1 pad per day) in the groups A and B, respectively, was: after 1 month – 22 and 16 %, after 6 months – 64 and 54 %, after 12 months – 78 and 78 %. Urinary incontinence in the groups A and B was as follows: mild (2–3 pads per day): after 1 month – 40 and 34 %, after 6 months – 30 and 32 %, after 12 months – 20 and 18 %; moderate (4–5 pads per day): after 1 month – 20 and 26 %, after 6 months – 6 and 10 %, after 12 months – 2 and 2 %; severe (6 pads or more): after 1 month – 18 and 24 %, after 6 months – 0 and 4 %, after 12 months – 0 and 2 %.Conclusion. Early removal of the urethral catheter (2 days) in patients who underwent laparoscopic radical prostatectomy is a relatively safe method that improves the restoration of urinary continence. Введение. В настоящее время нет единого мнения о сроках безопасного удаления уретрального катетера у пациентов, перенесших радикальную простатэктомию.Цель исследования – оценить безопасность и функциональные результаты раннего удаления уретрального катетера после лапароскопической простатэктомии.Материалы и методы. В период с января 2020 г. по апрель 2021 г. в исследование были включены 100 пациентов с раком предстательной железы, которым одним хирургом выполнена лапароскопическая простатэктомия (экстраи трансперитонеальным доступами). В группу А (n = 50) вошли пациенты, которым уретральный катетер был удален на 2-е сутки после оперативного вмешательства; в группу В (контрольную) (n = 50) – пациенты со стандартным сроком удаления катетера (14-е сутки).Результаты. В группе А по результатам цистографии у 3 (6 %) пациентов определялась экстравазация контрастного препарата из зоны уретровезикального анастомоза, принято решение о продлении катетеризации сроком до 10–14 сут. У 7 (14 %) пациентов после удаления уретрального катетера возникла острая задержка мочеиспускания: у 2 – непосредственно после удаления катетера, у 5 – через 2–7 сут после удаления катетера. Данным пациентам выполнена повторная установка уретрального катетера сроком на 2–3 сут. У 1 (2 %) из этих пациентов после удаления катетера возникла повторная задержка мочи, которая была разрешена однократной катетеризацией мочевого пузыря. В группах А и В частота полного восстановления удержания мочи (0–1 прокладка в сутки) через 1 мес составила 22 и 16 %, через 6 мес – 64 и 54 %, через 12 мес – 78 и 78 % соответственно. Частота недержания мочи легкой степени (2–3 прокладки в сутки) через 1 мес – 40 и 34 %, через 6 мес – 30 и 32 %, через 12 мес – 20 и 18 %; средней степени (4–5 прокладок в сутки) через 1 мес – 20 и 26 %, через 6 мес – 6 и 10 %, через 12 мес – 2 и 2 %;тяжелой степени (6 прокладок или более в сутки) через 1 мес – 18 и 24 %, через 6 мес – 0 и 4 %, через 12 мес – 0 и 2 %.Заключение. Раннее удаление уретрального катетера (2-е сутки) у пациентов, перенесших лапароскопическуюпростатэктомию, – относительно безопасный метод, позволяющий ускорить динамику восстановления удержания мочи

APPLICATION IMMUNOHISTOCHEMICALLY RESEARCH METHODS IN THE DIAGNOSIS OF PROSTATE CANCER

Introduction. The actual problem of modern urology remains differential diagnostics of various diseases of the prostate gland. The purpose of the study. Increasing the effectiveness of differential diagnosis of diseases of the prostate. Materials and methods. In the biopsy specimens of patients with benign prostatic hyperplasia (BPH) and prostate cancer (PCa), an immunohistochemical study of the production of the Ki-67 proliferation marker, matrix metalloproteinase-9, the matrix metalloproteinase inhibitor TIMP-1, and the distribution of collagen type IV was performed. Results. A moderate positive correlation was found between Gleason gradation and the cell proliferation index for Ki 67 (rs = 0.674) and a moderate negative correlation of Gleason gradation with the level of production of matrix metalloproteinase-9 (rs = -0.660). A weak significant negative correlation was established between the level of proliferative cell activity and the production of  MMP-9 tumor cells (rs = -0.369). A significant decrease in the level of MMP-9 and TIMP-1 in adenocarcinoma of different grades was revealed. The invasive properties of tumor cells, expressed in the destruction of collagen of the IV type of the basal membrane and connective tissue prostatic stroma, are mediated by the imbalance between MMP-9 and the protein blocking this enzyme - TIMP-1, whose production decreases in adenocarcinomas of different grades compared with BPH. Conclusions: 1. BPH is characterized by high production of MMP-9 type, which destroys the collagen of the basal membranes and stroma, the proteolytic action of which is blocked by the high content of TIMP-1

Risk factors and methods for prevention of lymphogenic complications in oncourological operations in pelvic area (systematic review)

Radical prostatectomy and cystectomy with pelvic lymphatic dissection are the most common operations in oncourology. Development of lymphatic complications, such as lymphocele, lymphorrhea and lymphedema, often complicates their implementation. However, not all lymphatic complications manifest themselves clinically and require surgical treatment. There are many risk factors and methods for preventing lymphogenic complications during oncourological operations in the pelvic area. In this article, we will review potential provocative factors that should be considered when performing oncourological interventions in the pelvis, as well as methods for their prevention, which can minimize the lymphogenic complications

Urethral Strictures after Transurethral Surgery: Treatment and Histological Issues

Introduction. The development of upper and lower urinary endoscopic surgery has brought about an increase in the number of urethral strictures after transurethral procedures.Material and methods. A retrospective analysis was performed involving the treatment results of 72 patients with urethral strictures after transurethral surgery in 2011-2016. All the patients underwent standard examination, including US, residual urine analysis, uroflowmetry, retrograde and micturating urethrography, IPSS and QoL questioning and general clinical tests.Results and discussion. The median of observation comprised 28 months. Bulbous urethra appeared to be the most frequent localisation of urethral strictures (87.5 %). The median stricture length was 2 cm with the mean maximum urine flow rate equal to 5.9 ± 2.7 mL/s. The median IPSS score counted 25 points. The type and number of surgical procedures were as follows: internal optic urethrotonomy (29), anastomotic urethroplasty (18), single-stage skin flap urethroplasty (3), single-stage urethroplasty using buccal mucosa graft (17), multiple-stage urethroplasty using buccal mucosa graft (1), meatotomy (1), single-stage navicular fossa urethroplasty using buccal mucosa graft (1). Internal optic urethrotonomy was to be effective in 52 % cases, while other surgical procedures showed 89 % effectiveness. The pathomorpho-logic studies revealed severe inflammation without signs of stroma fibrosis within urethral strictures.Conclusion. Transurethral endoscopic procedures appear to be the main causative factor (in 54 % cases) for iatrogenic urethral strictures

Evaluation of surgical complications incidence after radical cystectomy

Objective: to study the frequency of surgical complications and postoperative mortality after radical cystectomy (RCE).Material and methods. In study included 107 patients who underwent RCE by one surgeon. Starting in 2015, the protocol for accelerated recovery of patients after surgery, ERAS was applied in all patients undergoing RCE. The frequency of complications and mortality was studied depending on the age of the patients and the ERAS protocol. There were 84 male (78.5 %) and 23female (21.5 %) in this study. All patients were divided into 2 groups: 1st group — 89 (83.0 %) people younger 75 years and 2nd group — 18 (17.0 %) people from 75 years and older. Depending on the application of the ERAS protocol, patients in each group were divided into 2 subgroups. Group 1st consists of subgroups: 1(A) — 40 (45.0 %) patients with ERAS protocol, 1(B) — 49 (55.0 %) patients without ERAS protocol. Group 2nd also consists of subgroups: 2(A) — 8 (44.4 %) patients with ERAS protocol, 2(B) — 10 (55.6 %) patients without ERAS protocol. The average age of the patients was 65.5 (32—85) years.Results. Totally, over the 90-day period after the operation, 55 cases (51.4 %) of complications were recorded: Clavien—Dindo I—II in 1st group — 27 (30.3 %), in 2nd group — 8 (44.4 %). Complications of Clavien—Dindo III—IV in the 1st group — 15 (16.8 %), in the 2nd group — 5 (27.7 %). The overall 90-day mortality was 10 cases (9.3 %): in 1st group — 8 (9.0 %) patients, in 2ndgroup — 2 (11.1 %) patients. According to the comparative study of the use of the ERAS protocol in subgroup 1(A), the incidence of complications of the Clavien—Dindo I—II category was noted in 11 (27.5 %) patients, and in subgroup 1(B) in 16 (32.6 %) patients. Complications of Clavien—Dindo Ш—IV in subgroup 1(A) were observed in 5 (12.5 %) patients and in subgroup 1(B) — in 10 (20.4 %) patients; in subgroup 2(A), the incidence of Clavien—Dindo I—II complications was noted in 3 (37.5 %) patients, and in subgroup 2(B) — in 5 (50.0 %) patients. Complications of Clavien— Dindo III—IV in subgroup 2(A) were observed in 2 (25.0 %) patients and in subgroup 2(B) — in 3 (30.0 %) patients. Thus, the ERAS protocol decreased the number of complications in the subgroup 1(A) compared to the subgroup 1(B) (z = 1.44; p = 0.08) and between the subgroup 2(A) and 2(B) (z = 1.39; p = 0.09). Also there was an increase in the number of complications in older subgroups: in subgroup 2(B) compared with subgroup 1(B) (z = 1.86; p = 0.068).The 90-day mortality in subgroup 1(A) was in 3 (7.5 %) cases, 1(B) — 5 (10.2 %) cases. The 90-day mortality in subgroups 2(A) was in 1 (12.5 %) case, in subgroup 2(B) was 1 (10.0 %) cases. Repeated hospitalization for the first 90 days was 14 (13.0 %) cases, with differences in the frequency of rehospitalization depending on age and application of the ERAS protocol.Conclusion. RCE is an acceptable method of treatment in patients of the older age group and should be performed in hospitals with experience of regular treatment of this nosology. Application of the ERAS protocol (accelerated recovery after surgery) in patients undergoing RCE allows, regardless of age, to reduce the incidence of early postoperative surgical complications and mortality