[3D reconstruction of prostate as the way to personalized surgical planning]

A brief overview of current data on the use of three-dimensional (3D) reconstructions of the prostate for preoperative planning of radical prostatectomy (RP) is provided in the article. Non-systematic literature review in PubMed and Embase was carried out. The original articles were selected dedicated the use of 3D reconstruction of the prostate prior to RP. The use of 3D modeling plays an important role in the personalized approach to surgical treatment, namely for RP. This technique provides detailed information regarding periprostatic anatomy, localization of positive biopsy specimens, the suspicious lesions, which in turn affects the incidence of positive surgical margins. 3D reconstruction of the prostate is a useful tool for surgical planning, physician education and patient consultation. However, the use of this method in routine clinical practice is difficult, since the preparation of the model is not automated and there is a lack of studies.

[The role of expression of monocarboxylates of the first and fourth types (MCT1, MCT4) by tumor and stromal cells of prostate cancer in determining the prognosis and the efficiency of definitive treatment]

AIM

A search for new methods for diagnosing clinically significant prostate cancer is of importance due to the insufficient accuracy of modern methods in detecting aggressive tumors. One of the promising opportunities for the early diagnosis of clinically significant prostate cancer is the assessment of the glycolytic profile of the tumor by determining the expression of monocarboxylates (MCT) types 1 and 4 in tumor cells, as well as in adjacent stromal cells.

MATERIALS AND METHODS

An analysis of patients of who underwent radical prostatectomy at the Institute of Urology and Reproductive Health of Sechenov University from 2015 to 2017 was carried out. The patients with histologically confirmed prostate adenocarcinoma were included in the study. Among them, the presence or absence of biochemical recurrence during the first year was studied. An immunohistochemical (IHC) study of postoperative specimen was performed to determine the expression of MCT1 and MCT4 by tumor and stromal cells. The correlation between the intensity of their expression and the risk of biochemical recurrence and the tumor characteristics was evaluated.

RESULTS

High membrane expression of MCT1 directly correlated with high stromal expression of MCT4 (r=0.314, p<0.003). A significant direct correlation was found between the predominance of stromal expression of MCT4 over membrane expression and biochemical recurrence (r=0.403, p<0.001), as well as a high ISUP group (4 and 5) (r=0.294, p=0.005).

CONCLUSIONS

Determination of the level of expression of type 1 and 4 monocarboxylate transporters in adenocarcinoma cells and tumor stromal cells can become an effective tool for risk stratification, and may also predict the biological behaviors of the prostate cancer and the efficiency of definitive treatment.

[Calico-venous fistulae: an intrarenal complication of percutaneous nephrolithotomy]

Bleeding is a serious complication of percutaneous nephrolithotomy (PCNL). A rare cause of gross hematuria is a calico-venous fistula. A clinical case of successful intraoperative diagnosis and treatment of calico-venous fistula during PCNL is presented in the article. Description of a clinical case. A patient J., 53 years old, underwent examination and treatment at the Institute of Urology and Reproductive Health, FGAOU VO I.M. Sechenov First Moscow State Medical University with a diagnosis of staghorn stone of the right kidney, a stone of the left kidney, chronic right-side pyelonephritis. On June 15, 2021, mini-PCNL was performed for the staghorn stone of the right kidney. The procedure seemed to be unremarkable, but during intraoperative antegrade pyelography, the inflow of contrast agent from the lower calyxes into the posterior segmental vein of the right kidney was detected, which was managed by creating sufficient traction of the nephrostomy drainage. Communication of the collecting and venous systems of the kidney is associated with a risk of both severe gross hematuria and urine flow into the venous bed. The urine flow into the bloodstream may result in hemodynamic disturbances, up to collapse followed by cardiac arrest. In order to prevent complications of PCNL it is necessary to analyze the kidney anatomy based on three-dimensional modeling of contrast- enhanced computed tomography. A calicovenous fistula can be a source of risk of bleeding and severe complications. To minimize intraoperative damage to parenchymal structures, an analysis of three-dimensional modeling of a kidney in patients with staghorn calculus based on computed tomography is required, which allows rational planning of surgical tactics.

[Adherent Perinephric Fat: a prognosis and influence of perioperative results of organ-sparing procedures in localized kidney parenchyma tumors]

The results of recently published articles on the etiology and pathogenesis of "Adherent Perinephric Fat" (APF) are presented in the review. The current possibilities for predicting the presence of APF based on clinical data and imaging methods are highlighted, as well as the to an influence of ARF on perioperative results of organ-sparing procedures using various surgical approaches in patients with localized kidney parenchyma tumors.

[Analysis of the results of ERAS protocol in real-life clinical practice AFTER radical cystectomy (the first prospective multicenter study in Russia)]

AIM

to carry out a multicenter prospective analysis of the results of the ERAS protocol in patients undergoing radical cystectomy in real-life clinical practice. The aims of the study were to assess the complication and mortality rate after radical cystectomy using the ERAS protocol and to assess how often ERAS protocol was imple- mented.

MATERIALS AND METHODS

a multicenter study was carried out in 4 clinics in Russia. A total of 134 patients who underwent radical cystectomy in 2017 were prospectively analyzed. Open and laparoscopic radical cystectomy was performed in 35 (26.1%) and 99 (73.9%) patients, respectively. Bricker procedure prevailed as a method for urine derivation (91.7%). Complication and mortality rate, and each principle of ERAS protocol was analyzed both in the general sample of patients and separately for open and laparoscopic radical cystectomy.

RESULTS

length of hospitalization before the radical cystectomy was 1 (1-2) day. The median duration of surgery was 260 (205-300) minutes, median blood loss was 300 (200-400) ml. The median of the patients time in ICU was 1 (0-2) day. A total of 95 (70%) complications were recorded in the 90-day period after the surgery, including Clavien I-II category in 52 (38.8%) cases and Clavien III-IV in 43 (32%) cases. Of these, gastrointestinal tract complications were predominated. Gastroparesis requiring a nasogastric tube was observed in 16 (11.9%) patients. Ileus developed in 43 (32.1%) cases, and 22 patients (16.4 %) were managed conservatively; however, 21 patients (15.7%) undergone to reoperation. A 90-days mortality reached 5.2% and the main causes included multiple organ failure as a complication of peritonitis, acute heart failure after myocardial infarction and massive bleeding. Re-hospitalization rate was 9.7% (n=13). Length of stay was 12 (9-16) days. According to univariate and multivariate analysis, an absence of antibacterial prophylaxis, a history of coronary heart disease and the patients age more than 75 years were predictors of an increased complication rate. A 30-days mortality rate is 5.2%, and re-hospitalization was required in 9.7% (n=13) cases. An average length of stay was 12 (9-16) days. Frequency of implementation of ERAS protocol in each of the participating clinic varied. Open and laparoscopic radical cystectomy have insignificant differences in some intra- and postoperative parameters, but, in general, both approaches are comparable in terms of complications, mortality, and length of stay.

CONCLUSION

1. Despite the use of the ERAS protocol, radical cystectomy has a high frequency of complications (up to 70%); most of them are Clavien I-II. A 30-days mortality rate is 5.2%, and re-hospitalization is required in 9.7% cases. 2. Univariate and multivariate analysis showed that an absence of antibacterial prophylaxis, a coronary heart disease and the patients age more than 75 years are predictors of an increased complication rate. 3. Open and laparoscopic radical cystectomy have insignificant differences in some intra- and postoperative parameters, but, in general, both approaches are comparable in terms of complications, mortality, and length of stay. 4. To obtain more convincing data on the ERAS protocol after radical cystectomy, long-term studies are required.

[3D-technologies in planning and navigation for laparoscopic interventions in patients with renal and ureteric stones]

AIM

to evaluate the possibilities and efficiency of using 3D technologies for the laparoscopic interventions in patients with renal and ureteric stones.

MATERIALS AND METHODS

A retrospective analysis of the results of surgical treatment of patients with renal and ureteric stones performed in the urology clinic of the I.M. Sechenov First Moscow State Medical University of Minzdrav of Russia for the period from January 2012 to December 2017 was carried out. During this period a total of 4958 interventions were done. Among them, 98 laparoscopic (1.97%) surgeries were performed, including nephron-sparing interventions (n=47; 48%), pyelolithotomy (n=15; 15.3%), ureterolithotomy (n=32; 32.65%) and partial nephrectomy (n=4; 4.05 %). The average patients age was 55.76+/-10.5 (29-80) years. There were 51 men (52%) and 47 women (48%). The mean stone density was 1237.6+/-354.6 HU (from 500 to 1913 HU). In 14 (22.9%) cases, nephrostomy tube or ureteric stent had been put before surgery. In addition, 40 (40.8%) patients previously underwent one surgical intervention on the kidneys and 17 patients with urinary stone disease (17.3%) underwent surgery more or equal 2 times. 88 (89.8%) patients had severe concomitant diseases and the most common pathology in 51 (52.0%) patients with urinary stone disease was arterial hypertension. In 11 (11.2%) cases, the interventions were performed in patients with abnormal kidneys, including horseshoe kidney (n=6; 6.1%), duplicated collecting system (n=3; 3.1%) and pelvic kidney (n=2; 2%). In addition to standard preoperative diagnostic methods in 22 cases (22.4%) the 3D-planning and multivariate virtual performing of intervention based on the multidetector computer tomography scan was done using Amira 3D-modeling program. Among these patients, virtual interventions were performed prior to all pyelolithotomy and partial nephrectomy. Intraoperative data of virtual constructions were used by surgeons as navigation. The interventions were performed by seven urologists at the clinic with various experience in laparoscopic surgery.

RESULTS

The mean duration of laparoscopic pyelolithotomy, laparoscopic partial nephrectomy, laparoscopic ureterolithotomy and laparoscopic nephrectomy was 183.2+/-69.6, 201.3+/-35.2 min, 97.6+/-43.7 and 165.4+/-92.3 min, respectively. The minimal blood loss was observed during laparoscopic ureterolithotomy (53.33+/-31.2 ml). During these interventions, in 8 cases (8.16%) a flexible endoscope was used for inspection and complete removal of stones. Intraoperative complications were noted in 6 patients (6.1%). There were 4 conversions to open surgery (4.1%). Postoperative surgical complications were observed in 1 (1%) patient, while non-surgical complications developed in 4 patients (4.1%). There was no mortality.

CONCLUSION

Laparoscopic access for the treatment of patients with urinary stone disease should be used for the treatment of patients with large, long-standing ureteral calculi and patients with kidney stones who have concomitant pathology of kidney or upper urinary tract (UPJ obstruction, kidney tumors) requiring surgical intervention. Laparoscopic access should be considered primarily for the planning of laparoscopic partial nephrectomy and laparoscopic nephrectomy in patients with urinary stone disease. The use of 3D computer-assisted technologies is advisable for patients with urinary stone disease and abnormal kidneys if laparoscopic pyelolithotomy, partial nephrectomy or ureterolithotomy is planned.

[Use of local baroimpulse therapy in the treatment of patients with chronic abacterial prostatitis / chronic pelvic pain syndrome and erectile dysfunction]

AIM

To study the efficiency of local baroimpulse therapy (BIT) in the complex treatment of patients with chronic abacterial prostatitis/chronic pelvic pain syndrome (CP/CPPS) and erectile dysfunction (ED).

MATERIALS AND METHODS

A total of 112 men with confirmed diagnosis of CP/CPPS and ED, who received drug therapy according to the standards and guidelines were included in the study. In the main group (n=68) all patients additionally received local BIT in the form of rectal pneumovibromassage (PVM) of the prostate (totally, 10 procedures). In the control group (n=44) only standard treatment was provided. The efficiency of therapy was assessed based on the complex clinical examination, laboratory tests and imaging methods.

RESULTS

At the visit 2 (1 month after the start of therapy) there were significant differences in clinical (resolution of symptoms of CP/CPPS and improvement of erectile function), laboratory and imaging criteria between 2 groups. The rectal PVM using apparatus MKV-01 "Inavita" resulted in decrease the activity of inflammation process and levels of pro-inflammatory cytokines, increase of flow rate and intraprostatic blood flow. According to the analysis of long-term results, after 6 months of therapy the remission was seen in the most of patients in the main group (79.4%), which was 40.8% higher than in the control group.

CONCLUSION

The use of local BIT by mean of rectal PVM allows to increase efficiency of complex treatment of patients with CP/CPPS and ED.

[Methods for training of robot-assisted radical prostatectomy]

Robotic surgery is a future method of minimal invasive surgery. Robot-assisted radical prostatectomy (RARP) is a common method of surgical treatment of prostate cancer. Due to significant differences of the surgical technique of RARP compared to open or laparoscopic radical prostatectomy (LRP) new methods of training are needed. At the moment there are many opinions how to train physicians best. Which model is the most effective one remains nowadays controversial.

OBJECTIVE

Analyze currently available data of training methods of RARP. Determine the most effective training model and evaluate its advantages and disadvantages. Establish a standardized plan and criteria for proper training and certification of the entire surgical team.

MATERIAL AND METHODS

Literature review based on PubMed database, Web of Science and Scopus by keywords: robot-assisted radical prostatectomy, training of robot-assisted prostatectomy, training in robot-assisted operations, a learning curve of robot-assisted prostatectomy, virtual reality simulators (VR-simulators) in surgery.

RESULTS

According to the literature in average 18 to 45 procedures are required for a surgeon to achieve the plateau of the learning curve of the RARP. Parallel training, pre-operative warm-up and the use of virtual reality simulators (VR-simulators) can significantly increase the learning curve. There are many described models of RARP training.

CONCLUSIONS

The absence of accepted criteria of evaluation of the learning curve does not allow to use this parameter as a guide for the surgeon's experience. Proper training of robotic surgeons is necessary and requires new methods of training. There are different types of training programs. In our opinion the most effective training program is when a surgeon observes the performance of tasks or any steps of operation on the VR-simulator, then he performs them and analyzes mistakes by video recording. Then the surgeon observes real operations and performs some steps of the operation which are already leant on the simulator under supervision of the mentor and analyzes mistakes by video recording. Thus, mastering first the simple stages under supervision of a mentor, the surgeon effectively adopts the surgical experience from him. It is necessary to train not only the surgeons but also the entire surgical team.

[The morphologic results of organ-sparing interventions in patients with renal tumor aged up to 40 years and older]

AIM

to evaluate the features pathologic results of organ-sparing interventions in patients aged up to 40 years and older and assess an influence of patient age on the recurrence-free survival in case of pathologically proven renal cell cancer.

MATERIALS AND METHODS

A retrospective analysis of laparoscopic organ-sparing removal of kidney tumors in 314 patients performed from January 2012 to May 2017 was conducted. The mean patient age was 54.4+/-10.9 (25-78) years. There were 178 males (56.7%) and 136 females (43.3%). All patients were divided into two groups. In Group 1 a total of 37 patients aged less or equal 40 years (11.8%) were included and Group 2 consisted of 277 patients (88.2%) over 40 years. In Group 1 there was no family cases of renal cell cancer.

RESULTS

In Group 1 malignant tumors were more common (n=33 cases (89.2%)), and benign tumors were diagnosed in 4 (9.8%) cases. Among patients older than 40 years the malignant and benign tumors were determined in 242 cases (87.4%) and 35 cases (12.6%), respectively. It was estimated that there were no differences in neither malignant tumors rate (p=0.75), nor in proportion of different pathologic forms of benign (p=0.68) and malignant neoplasms (p=0.25), nor in proportion of various degrees of anaplasia (=0.33). A mortality rate was 0.6% (2 patients in Group 2), and there was 3 relapse (1.1%). A proportion of censored cases was 99.4% for overall survival and 98.9% for recurrence-free survival. A point estimate of overall survival after 36-months follow-up was 35.77+/-0.16 months. The mean disease-free survival was 35.47+/-0.24 months. The survival differences between two groups were not significant due to absence of relapse and mortality in patients aged less or equal 40 years.

CONCLUSION

During the planning of surgical treatment of patients with kidney tumors aged less or equal 40 years a preference to organ-sparing interventions should be given. The postoperative genetic counselling is recommended to exclude hereditary renal cell cancer. Considering a high risk of local recurrence in all patients aged less or equal 40 years meticulous and regular follow-up is needed.

ACUTE DECOMPENSATION OF HYPERTENSIVE HEART DISEASE IN PATIENT WITH MALIGNANT URINARY BLADDER PARAGANGLIOMA: STAGES OF DIAGNOSTICS AND TREATMENT

Hypertensive heart disease with biventricular cardiac failure is not common in clinical practice. This diagnosis requires an extensive diagnostic search. We present the clinical case of the male patient of 38 aged. He was admitted to the clinic with heart failure 3-4 NYHA class. EchoCG revealed symmetric hypertrophy of the left ventricle up to 18 mm without its dilatation, a decrease in ejection fraction up to 42%, restrictive hemodynamics, overload of the right chambers, severe pulmonary hypertension (60 mm Hg). The clinical status included persistent arterial hypertension (180-220 and 120-150 mm Hg), effusion in both pleural cavities and pericardium, ascites, renal failure. During examination (multispiral computed tomography, magnetic resonance imaging, scintigraphy with 131I-MIBG), bladder paraganglioma was diagnosed (normatenafrin 1468 μg/day). The resection of the tumor was performed, according to immunohistochemical research – neuroendocrine carcinoma, G1. After 3 months a partial regression of hypertension and cardiac failure was observed with the preservation of a high level of creatinine. The criteria and differential diagnosis of the hypertensive heart disease and the syndrome of primary myocardial hypertrophy, diagnostics of the urinary bladder paraganglioma, complex mechanisms of myocardial damage within the pheochromocytoma and its prognosis are discussed.

[Computer-assisted laparoscopic surgery for renal carcinoma]

AIM

To investigate the effectiveness and benefits of using 3D planning and virtual surgery in the management of patients with localized renal carcinoma undergoing laparoscopic surgery.

MATERIALS AND METHODS

A retrospective analysis was performed on 558 patients with renal cell carcinoma (RCC) who underwent surgical treatment at the Clinic of Urology, I.M. Sechenov First MSMU from January 2012 to May 2017. Of them, 244 (43.7%) and 314 (56.3%) patients underwent laparoscopic radical nephrectomy (LRN) and laparoscopic partial nephrectomy (LPN), respectively. In addition to the standard diagnostic work-up, 248 (44.4%) patients underwent multispiral computed tomography (MSCT) for 3D modeling and virtual surgery using the 3D modeling program Amira. Matched pairs of patients with and without 3D planning were selected based on similarity of urologists experience in performing the operation, the size and location of the tumor (relative to the renal segment, anterior and posterior surfaces), and the surgical approach. As a result, two homogeneous subgroups of patients were chosen comprising those who underwent LRN (22 pairs of patients) and LPN (53 pairs of patients).

RESULTS

Patients with RCC who underwent LPN with 3D planning had a significant advantage over patients without virtual planning: by warm ischemia time 12.0+/-6.4 min (p=0.010), operative time 113.4+/-39.4 min (p=0.0001), blood loss 102.8+/-98.2 ml (p=0.001). Among patients with RCC who underwent LRN, the subgroup with 3D planning also had an advantage: operative time was 135.2+/-27 and 202.9+/-55.5 min (p=0.0001), blood loss was 143.2+/-137,4 and 472,0+/-395,4 ml (p=0,014), and regarding the rate of intraoperative (p=0,017) and postoperative (p=0,017) complications.

CONCLUSION

The use of computer-assisted 3D planning and virtual operations improves immediate results of surgery in RCC patients undergoing organ-sparing and organ-removing laparoscopic surgery.

[Laparoscopic segmental ureteral resection with ileal-ureter substitution for ureteral urothelial carcinoma]

Ureteral resection for the mid-ureter urothelial carcinoma is the operation of choice in patients with low-grade tumors. However, extensive excision within normal tissues may lead to difficulty in appropriate apposition of the ends of the ureter, while incomplete resection increases the risk of oncological progression. This article describes the first experience with laparoscopic segmental ureteral resection with the ileal - ureter substitution for mid-ureter urothelial carcinoma. In this case, a short non-reconfigurated segment of the ileum was interposed between the distal and proximal ends of the resected ureter. Operative time was 230 min, and blood loss was less than 100 ml. No complications were observed. The patients postoperative hospital stay was seven days. Follow-up examination 12 months after surgery showed no evidence of the disease progression and preserved normal renal function. The proposed method may be considered as an alternative treatment for carefully selected patients.

[Non-biological 3D printed simulator for training in percutaneous nephro- lithotripsy]

AIM

To develop a non-biological 3D printed simulator for training and preoperative planning in percutaneous nephrolithotripsy (PCNL), which allows doctors to master and perform all stages of the operation under ultrasound and fluoroscopy guidance.

MATERIALS AND METHODS

The 3D model was constructed using multislice spiral computed tomography (MSCT) images of a patient with staghorn urolithiasis. The MSCT data were processed and used to print the model. The simulator consisted of two parts: a non-biological 3D printed soft model of a kidney with reproduced intra-renal vascular and collecting systems and a printed 3D model of a human body. Using this 3D printed simulator, PCNL was performed in the interventional radiology operating room under ultrasound and fluoroscopy guidance.

RESULTS

The designed 3D printed model of the kidney completely reproduces the individual features of the intra-renal structures of the particular patient. During the training, all the main stages of PCNL were performed successfully: the puncture, dilation of the nephrostomy tract, endoscopic examination, intra-renal lithotripsy.

CONCLUSION

Our proprietary 3D-printed simulator is a promising development in the field of endourologic training and preoperative planning in the treatment of complicated forms of urolithiasis.

[Complications of the holmium laser enucleation of prostate for benign prostatic hyperplasia]

INTRODUCTION

With growing experience in the HoLEP, it can replace TURP as the "gold standard" for the surgical management of BPH, and therefore this technique is the most studied surgical modality. Despite the proven effectiveness of HoLEP in the treatment of patients with BPH, its widespread use has been associated with both intra- and postoperative complications.

AIM

To improve the results of surgical management of patients with BPH.

MATERIAL AND METHODS

The study comprised 310 patients who underwent HoLEP for BPH. HoLEP was performed using the Gillings technique.

INCLUSION CRITERIA

presence of LUTS (Qmax<15 ml/s, Qav<10 ml/s, presence of residual urine, I-PSS score> 5, QoL score> 2), absence of an active inflammatory process of the urogenital organs.

RESULTS

Intraoperative complications included severe hemorrhage in 16 (5.2%), the bladder wall injury in 17 (5.5%) and the ureteral orifice injury in 2 (0.6%) patients. 275 (88.7%) had no intraoperative complications. Early postoperative complications included fever in 4 (1.3%), the bladder tamponade that required cystoscopy and evacuation of blood clots in 7 (2.3%) and acute urinary retention in 36 (11.8%) patients. 263 (84.6%) patients had no postoperative complications. Long-term postoperative complications comprised urinary incontinence in 39 (12.6%) patients and urethral strictures requiring surgical treatment in 9 (2.9%) patients. There were no long-term complications in 262 (84.5%) patients.

CONCLUSION

HoLEP is an effective and safe surgical modality for treating patients with BPH with minimal complications, suitable for any size of the prostate.

[Application of 3D soft print models of the kidney for treatment of patients with localized cancer of the kidney (a pilot study)]

AIM

To evaluate the possibility of using 3D-printing in the management of patients with localized kidney cancer.

MATERIALS AND METHODS

The study comprised five patients with localized kidney cancer who were treated at the Urology Clinic of the I.M. Sechenov First Moscow State Medical University from January 2016 to April 2017. Along with the standard examination, the patients underwent multispiral computed tomography (MSCT) to produce patient-specific 3D-printed models of the kidney tumors using 3D modeling and 3D printing. To evaluate the effectiveness of using 3D-printed models, two-stage preoperative planning was conducted, and five surgeons were surveyed using a four-question multiple choice questionnaire. At the first stage, the planning of operations was carried out based on MSCT findings. At the second stage, the surgeons were given patient-specific soft 3D models of the kidney with a tumor for preoperative training. After preoperative training, patients underwent laparoscopic resection of the kidney with a tumor.

RESULTS

According to the survey results, each of the participating surgeons at least once changed surgical plan based on data obtained with 3D printed models of the kidney with the tumor. The implementation of preoperative training using 3D printed models of the kidney turned out to be effective. All patients underwent laparoscopic surgery performed by a single surgeon with extensive experience in this type of surgery. The mean operative time was 187 minutes. All operations were performed with main renal artery occlusion. The men warm ischemia time was 19.5 minutes and the mean blood loss was 170 ml. There were no conversions to open surgery and organ-removing operations. There were no postoperative complications or deaths. All surgical margins were negative. Morphological examination showed that four patients had renal cell carcinoma one patient had the oncocytoma.

CONCLUSION

The study demonstrated the promise of using 3D printing for preoperative planning and surgical performance due to a high-precision three-dimensional soft patient-specific model of the localized kidney.

[Application of 3D printing in urology]

The purpose of this article is to outline the role and possible applications of 3D printing in urology. At present, this technique provides the opportunity to choose the individual strategy of patient management, to conduct preoperative planning and surgical rehearsal; for medical specialists to reduce the learning curve in mastering modern complex surgical techniques, and for doctors and students to improve understanding of pathological processes in the kidney and the prostate gland.

[Prostate cancer of high oncological risk. urrent trends in diagnosis and surgical treatment]

A group of patients with high risk prostate cancer was identified in the late 1990s. Since then, management of this group of patients has undergone some serious changes. The article provides a brief overview of the most significant changes, primarily in surgical treatment, over the past 3 years. Besides, the authors present their views on perspective treatments and possible changes in the near future.

[Using of cell biocomposite material in tissue engineering of the urinary bladder]

In a systematic review, to present an overview of the current situation in the field of tissue engineering of urinary bladder related to the use of cell lines pre-cultured on matrices. The selection of eligible publications was conducted according to the method described in the article Glybochko P.V. et al. "Tissue engineering of urinary bladder using acellular matrix." At the final stage, studies investigating the application of matrices with human and animal cell lines were analyzed. Contemporary approaches to using cell-based tissue engineering of the bladder were analyzed, including the formation of 3D structures from several types of cells, cell layers and genetic modification of injected cells. The most commonly used cell lines are urothelial cells, mesenchymal stem cells and fibroblasts. The safety and efficacy of any types of composite cell structures used in the cell-based bladder tissue engineering has not been proven sufficiently to warrant clinical studies of their usefulness. The results of cystoplasty of rat bladder are almost impossible to extrapolate to humans; besides, it is difficult to predict possible side effects. For the transition to clinical trials, additional studies on relevant animal models are needed.

[The role of waterjet dissection in improving erectile function and continence after nerve-sparing prostatectomy]

INTRODUCTION

Erectile dysfunction (ED) and urinary incontinence (UI) following radical prostatectomy (RP) adversely impact patients psycho-emotional status reducing the quality of life and treatment satisfaction.

AIM

To investigate the rates of regaining continence and erectile function (EF) after nerve-sparing radical retropubic prostatectomy (NS-RRP) and nerve-sparing laparoscopic radical prostatectomy (NS-LRP) in the early postoperative period.

MATERIALS AND METHODS

The study comprised 116 patients who preserved sexual activity and the ability to have sex. 64 patients underwent standard resection of NVB (34 RRP and 30 LRP) and in 52 patients the NVB resection was performed using a waterjet dissector (WD) (30 RRP and 22 LRP). All operations were performed by one surgeon with the experience of over 350 RRP and 150 LRP. The study patients had low and moderate risk prostate cancer, according to DAmico risk classification.

RESULTS

Our study findings showed that patients who underwent the WD of NVB had significantly greater IIEF-5 scores (by 2.8 scores) at 8 weeks than after the standard NS-RP. After 6 month follow-up the scores increased by 3.5 points. Patients who underwent NS-RP + WD achieved a successful sexual intercourse 3 months after surgery (regardless of the use of PDE5 inhibitors). In the group of patients who underwent standard NS-RP, it took a longer time to achieve a successful sexual intercourse. Sixty-seven percent of patients who underwent NS-RP + WD were fully continent at one month follow-up after removal of urethral catheter, while most patients treated with standard NS-RP (41%) had mild stress UI. After 3 months follow-up, among patients who underwent NS-RP + WD only one patient had mild stress UI and the vast majority (95%) of patients were fully continent. At 6 months after removal of the urethral catheter there were no significant differences between the groups in regaining urinary continence.

CONCLUSIONS

Waterjet dissection of NVB significantly improves patients postoperative quality of life due to early recovery of urinary continence and EF.

[Tissue engineering of urinary bladder using acellular matrix]

INTRODUCTION

Tissue engineering has become a new promising strategy for repairing damaged organs of the urinary system, including the bladder. The basic idea of tissue engineering is to integrate cellular technology and advanced bio-compatible materials to replace or repair tissues and organs.

AIM

of the study is the objective reflection of the current trends and advances in tissue engineering of the bladder using acellular matrix through a systematic search of preclinical and clinical studies of interest.

MATERIALS AND METHODS

Relevant studies, including those on methods of tissue engineering of urinary bladder, was retrieved from multiple databases, including Scopus, Web of Science, PubMed, Embase. The reference lists of the retrieved review articles were analyzed for the presence of the missing relevant publications. In addition, a manual search for registered clinical trials was conducted in clinicaltrials.gov.

RESULTS AND DISCUSSION

Following the above search strategy, a total of 77 eligible studies were selected for further analysis. Studies differed in the types of animal models, supporting structures, cells and growth factors. Among those, studies using cell-free matrix were selected for a more detailed analysis.

CONCLUSION

Partial restoration of urothelium layer was observed in most studies where acellular grafts were used for cystoplasty, but no the growth of the muscle layer was observed. This is the main reason why cellular structures are more commonly used in clinical practice.

[Using cell technologies to treat urologic diseases]

Stem and progenitor cells being introduced into the body have the ability to stimulate regeneration of tissues and organs by differentiating into specialized cells. Stem cell therapy is used in urology to treat various disorders, including erectile dysfunction, urinary incontinence, Peyronies disease, and male infertility. This review presents the results of international preclinical and clinical research on stem cell based medications for treating the above diseases. The most promising appears to be the use of adipose tissue-derived mesenchymal stem cells.

[Indocyanine green fluorescent imaging in urology]

This paper gives an overview of the prospects for indocyanine green fluorescent imaging, which is used in different fields of surgery, transplantation and urology. This method offers new opportunities in angiography, lymphography; it allows measuring tissue perfusion and differentiating healthy tissue and tumors in real time. The safety of the method has been proven and its diagnostic value is being extensively studied.

[Concomitant use of abiraterone acetate and triptorelin in patients with castration-resistant prostate cancer]

The relevance of drug treatment for prostate cancer increases with the number of patients who develop castration resistance. Currently, no unified treatment regimen for castration-resistant prostate cancer exists, but the standard treatment for these patients is continuous androgen deprivation therapy. This paper presents the experience of concomitant use of abiraterone acetate and triptorelin in patients with castration-resistant prostate cancer. Ten patients with disease duration of 1.5 to 18 years and established castration resistance are currently being followed up. Nine of ten patients have long-term bone metastases, one patient has visceral metastases. The combination therapy produced a significant PSA decrease in nine patients and regression of bone lesions in two patients.

[ASSESSMENT OF THE RISK OF INCIDENTAL PROSTATE CANCER PROGRESSION]

At present, methodology based on the stage T1a or T1b is used to determine the risk of incidental prostate cancer (IPC) progression. This approach was developed before the introduction of prostate-specific antigen (PSA) into the practice of the urologist, and does not account of the degree of IPC. For the prediction of IPC progression, multifactorial prognostic model was created. This model is based on the analysis of two parameters--the total PSA level before the surgery and the Gleason score according to the results of morphological examination after transurethral resection of the prostate hyperplasia. This model has a high predictive value (AUC 86.6%) and can be easily used in practice. For the interpretation of the calculated results special table is formed that allows to assess the risk of progression over the next 3.5 years.

[3D-TECHNOLOGIES AS A CORE ELEMENT OF PLANNING AND IMPLEMENTATION OF VIRTUAL AND ACTUAL RENAL SURGERY]

The purpose of this article is to demonstrate the role of modern computer technologies in performing virtual and actual renal tumor surgery. Currently 3D modeling makes it possible to clearly define strategy and tactics of an individual patient treatment.

[UROLOGY LESSONS FOR COLORECTAL SURGEONS]

The anatomical and functional relationship of the pelvic organs is a prerequisite to the development of complications when performing surgical procedures in this anatomical region. Prevention and timely diagnosis of intraoperative injuries of both the urinary system organs and intestine, as well as well-coordinated work of urologist and colorectal surgeon team offer the opportunity to employ optimal tactics for the patient management.

[3D-TECHNOLOGY AS AN ELEMENT OF PLANNING, EFFECTIVE IMPLEMENTATION AND SURGICAL SIMULATION TRAINING IN STAGHORN NEPHROLITHIASIS MANAGEMENT]

Daily practice of a physician of any specialty is incomplete without an analysis of the data derived from the use of various imaging techniques. Over the past decade, there have been significant changes in the understanding of the clinical anatomy of the patient, which is largely the result of the introduction of modern computer technology in medicine.

[APPLICATION OF DIFERELIN AND ITS PERSPECTIVES]

The article presents a brief overview of luteinizing hormone-releasing hormone analogs in the treatment of prostate cancer. The authors report their experience with this drug class by an example of Diferelin. The experience with abiraterone in treatment of patients with hormonal resistance is described.

[RISK FACTORS FOR ANTERIOR URETHRAL STRICTURES AFTER TRANSURETHRAL RESECTION OF BENIGN PROSTATIC HYPERPLASIA]

OBJECTIVE

To determine the risk factors for anterior urethral strictures after transurethral resection of benign prostatic hyperplasia.

MATERIALS AND METHODS

The present study consists of a prospective and retrospective part. Prospective analysis of 110 patients who had undergone, at the urology clinic of First MSMU named after I.M. Sechenov in the period from January 2009 to February 2014 was performed transurethral resection (TUR) of the prostate. In the retrospective part, the case histories of 85 patients who were treated in the urology clinic First MSMU named after I.M. Sechenov from 2009 to 2013 with a diagnosis of urethral stricture were analysed. Of them, 29 cases urethral stricture occurred earlier after undergoing TURP. Patients from both sides were divided into two groups: group number 1 patients undergoing TURP for BPH who have not formed a urethral stricture, and group number 2 - patients who had urethral stricture formed.

RESULTS

According to the criteria for inclusion in group number 1 there were 40 patients who did not form a urethral stricture after TURP and 33 patients were included in the group number 2, in which the late postoperative period was complicated by the formation of a stricture of the urethra. Prostate volume was significantly different in both groups. In group number 1 prostate volume averaged 60 cm3±23 cm3 in group number 2 prostate size equaled an average of 80 cm3±24 cm3. (p<0,05). Having a urethral catheter or cystostomic drainage before surgery was observed in 12% (n=5) in the first group and 27% (n=9) in the second group. Duration of operative benefits was assessed at intervals up to 60 minutes and more than 60 minutes. Thus, the results in the first group are divided into 75% (30) 25% (10), respectively. In the second group, these values were 24,2% (n=8) and 75.8% (n=25). Diabetes mellitus was noted in a first group in 12.5% (n=5) of the patients, in the second group - 30% (n=10). The number of patients seen earlier for hypertension in the group, which did not form a urethral stricture, was 37,5% (n=13) and in the group with urethral strictures - 60,6% (n=20). Having chronic inflammation, which was confirmed upon subsequent morphologic examination of prostate tissue resection, were detected in the first group at 32,5% (n=13) patients and in the group number 2 at 66,6% (n=22) patients and was significantly higher in the second group (p<0,05).

CONCLUSIONS

The duration of TURP more than 60 minutes, prostate volume of more than 70 cm3, the presence of diabetes mellitus, and also chronic inflammation of the prostate significantly increases the risk of urethral stricture in the late postoperative period.

[Diagnosis and treatment of local recurrence of prostate cancer using hystoscanning and high-intensity focused ultrasound in patients after radical prostatectomy]

The study was aimed to the improvement of the diagnosis and treatment of patients with prostate cancer (PC). The study included 46 patients with recurrent prostate cancer after radical prostatectomy (RPE). The examination included contrast enhanced magnetic resonance imaging (endorectal coil 1.5T) and hystoscanning. All patients had local recurrence confirmed by the morphologically results of transrectal biopsy of the area of vesicourethral anastomosis. All patients underwent high-intensity focused ultrasound (HIFU). Before RPE, protate volume ranged from 21 to 102 cm3. The median age was 62 (46-68) years. PSA levels before a HIFU session ranged from 0.4 to 18 ng/ml. Nadir PSA level after 3 months of follow up was 0.1 ng/ml. Five-year disease-free survival in patients with locally recurrent prostate cancer after HIFU in the group of low cancer risk was 10 (81%), moderate risk--18 (57%), high risk--12 (42%). Contrast enhanced magnetic resonance imaging and hystoscanning are highly informative methods for diagnosis of local recurrence after radical prostatectomy, and HIFU can be categorized as highly effective treatment.

[Treatment of prostatic cancer with high intensity focused ultrasound (HIFU) using Ablatherm device]

High intensity focused ultrasound (HIFU) is a method of delivering acoustic energy to a focal point and thus destroying it, causing coagulation necrosis. Repeating the fires, the whole needed volume of organ can be treated without damaging the surrounding tissue. A total of 122 patients with biopsy-proven prostatic cancer (and 2 more patients had only high-grade PIN) have been treated in our clinic for 3.5 years using the Ablatherm device. Seventy one of them entered this study. They were followed up for six months to three years at a regular interval. Follow-up PSA measurements and control sextant biopsies were made. The median PSA nadir 1.5-3.0 months after treatment ranged from 0.10 ng/ml (in low-risk localized prostate cancer group) to 2.50 ng/ml (in patients with disseminated process). Negative control biopsies were registered in 74-77.7% patients with local prostatic cancer and in 60-68% patients with disseminated process. Of all the patients, 90% had undergone transurethral resection of the prostate before HIFU treatment. Such combination improved the efficacy of HIFU and significantly reduced treatment-related morbidity. Urinary stress incontinence grade 2 was observed in 1.6% and grade 3--in 0.8% of all the patients. No other severe complications occurred. The erectile function was preserved in 71.2% patients. Our results demonstrate efficacy and safety of HIFU. HIFU does not exclude other treatment options and can be repeated. HIFU seems to be a valid alternative treatment for patients with contraindications for radical surgery.

[Dynamic magnetic resonance prostatovesiculography in diagnosing prostatic cancer]

Dynamic MR prostatovesiculography (DMRP) is a new method of prostatic cancer diagnosis based on the ability of cancer tissue to accumulate contrast substance (omniscan) than benign tissue. Urologists from the I.M. Sechenov Moscow Medical Academy have examined 23 patients (5 patients with prostatic cancer and 18 suspects) who have undergone standard investigations (test for PSA, finger rectal examination, transrectal ultrasound investigation) and DMRP. DMRP detected prostatic areas suspected of malignancy. Taking biopsy from such areas verified diagnosis of prostatic cancer in 2 patients.

[Transpubic approach in radical prostatectomy]

Surgical interventions in prostate apex and urethral membranous part are difficult because these structures are in the depth of the small pelvis. Transpubic approach permits easy manipulations in this area. There are the following variants of this approach: symphysotomy, pubectomy, resection of superior horizontal rami of pubic bones, resection of inferior horizontal rami of pubic bones, clinoid resection of pubic bones. The simplicity, adequacy and convenience of different surgical manipulations are the advantages of transpubic approach. The clinoid resection of pubic bones is the optimal variant of this approach. In provides an adequate approach to operated organs, the integrity of pelvic ring is saved, as a result of which there are no severe orthopedic disorders in the nearest and remote postoperative periods. For determination of indications to transpubic approach, the comparative study of the transpubic and low-median approaches in radical prostatectomy was carried out in 50 male cadavers according to parameters proposed by Sozon-Yaroshevich in 1954. The type of constitution, height of symphysis, size and shape of the prostate puboprostatic ligaments, adhesion of ligaments to prostate, prostate position against symphysis, size of small pelvis venous vessels were taken into account. It was established that the angle of surgical action in wound in low-medium approach was 35-50 degrees, in transpubic approach--by 25-30 degrees more. Incline angle of surgical manipulation axis, which reflect the correspondence of surgical section to exposed organ's disposition, is very important in case of organ's immobile position. This angle in low-medium approach was 40 +/- 5 degrees, in transpubic--80-90 degrees. Dorsal venous plexus and urethrals membranous part are approachable if the prostate size is small, but if the prostate volume is more than 30 cm3 and symphysis is high (> 7 cm), it is very difficult to manipulate in this zone in low-medium approach. Transpubic approach warrants thorough and careful prostatectomy. Methods leading to disturbance of pelvic ring integrity (symphysotomy, pubectomy) have no advantages. Clinoid resection ensures the optimum view of operative field and satisfy the main requirements of surgical approach.