Evaluation of functional and oncological outcomes of localized prostate cancer after different minimally invasive therapeutic methods: A single center experience

OBJECTIVES

To study the functional and oncological results of minimally invasive treatment methods: cryoablation, brachytherapy, and high-intensity focused ultrasound (HIFU) therapy of localized prostate cancer in a single hospital.

METHODS

One hundred sixty patients with localized prostate cancer were treated with minimally invasive methods (53, 52, 55 patients with cryoablation, brachytherapy and HIFU therapy, respectively). Prostate-specific antigen and evaluation of post-procedure biopsies were used as an assessment. The review of functional indicators and quality of life was made with International Index of Erectile Function (IIEF-5), International Prostate Symptom Score (IPSS), maximum urinary flow rate (Qmax), quality of life (QoL) questionnaires.

RESULTS

Patients after cryoablation showed worse results of oncological control according to positive repeat biopsies, best indicators were observed after brachytherapy. When considering the IPSS results, there were statistically significantly worse scores in the brachytherapy group in the early postoperative period, these differences do not reach statistical significance in the late period in the brachytherapy and cryoablation groups. Patients in the cryoablation group showed worse indicators of IIEF-5; in the early postoperative period; in the late follow-up period, the indicators of erectile function in patients in the cryoablation group did not statistically significantly differ from those in patients after brachytherapy. Patients after HIFU therapy showed fewer cases of de novo erectile dysfunction during the follow-up period of 3 years, higher average IIEF-5 scores, lower IPSS scores and better QoL results.

CONCLUSION

The recurrence of prostate cancer was statistically significantly higher in the International Society of Urological Pathology (ISUP) 3 grade group. HIFU therapy had better urination indicators compared to other groups, that can be associated with the laser enucleation of prostatic hyperplasia. The advantage was noted in patients after HIFU therapy when comparing the parameters to the IIEF-5 thus, HIFU treatment had a better impact on patients' QoL with localized prostate cancer.

Steatocystoma multiplex of the scrotum. Clinical case

Steatocystoma multiplex is a disorder of the pilosebaceous unit characterized by multiple sebum-containing dermal cysts. We report the case of a 64-year-old male presented with multiple skin-colored, partially hyperemic cystic located in the scrotum area. They were accompanied by an active inflammatory process in the form of pain, swelling, hyperemia. The lesion was present for about 1 month. Previously, this patient had diagnosed with multiple steatocystoma located in the hip area and received surgical treatment.

At present, such reports in the scientific databases are presented sporadically, therefore we report on multiple steatocystoma of the scrotal localization due to its rarity.

Resection of the inferior vena cava in patients with kidney tumor and tumor thrombus

Renal cell carcinoma with inferior vena cava (IVC) thrombosis is a rare disease with a poor prognosis without surgical treatment. The presence of a tumor thrombus in the cavity of the main vessel in most cases is accompanied by massive bleeding during thrombectomy. To reduce the volume of blood loss, it is possible to use cardiopulmonary bypassto reduce the potential risks associated with blood loss and unstable hemodynamics. Sometimes tumor thrombosis can be growth into the vein wall or lead to occlusion IVC, we consider that it’s indication for resection of the IVC. Thrombectomy with laparotomy access can be performed even with type IV tumor thrombosis, if the thrombus is not fixed to the wall of the suprarenal IVC and surgeon have enough view of suprarenal segment.

This article presents a variant of surgical treatment of patients with right kidney cancer, type IV IVC thrombosis, occlusion infrarenal IVC and ileofemoral thrombosis. In both cases we made resection IVC – infrarenal segment in first case and suprarenal segment in second case.

[Dissolution of uric acid stones in the ureter]

INTRODUCTION

Uric acid stones (UA), consisting of uric acid/uric acid dihydrate, occur in 6.1-15.1% of all cases of urolithiasis in industrialized countries. At the same time, the frequency of these stones is directly dependent on age. Thus, the incidence of UA reaches 40% in men over 80 years of age and 27.3% in women over 90 years of age. UA are the only stones that are amenable to dissolution therapy with the use of citrate salts that alkalinize urine pH. A number of authors and European Association of Urology guidelines consider stone dissolution as a first-line therapy in the treatment of patients with UA, both as monotherapy and in combination with surgical procedures.

MATERIALS AND METHODS

The results of conservative treatment of 86 patients aged 28 to 78 years with radiolucent ureteral stones ranging in size from 3 to 25 mm and a density of 133 to 728 HU, who underwent 89 courses of stone dissolution therapy from 2011 to 2018, are presented in the article. They had no obstruction or were prestented. There were 52 men (n=55 courses) and 34 women (n=34 courses).

RESULTS

In 78 out of 89 clinical cases (87.6%), stone-free status was obtained within 14 to 181 days. Most often the duration of therapy was 30 days. In 11 (12.4%) cases the treatment was considered ineffective. However, only in 4 (4.5%) patients the stone size did not change, while in 7 (7.9%) cases it decreased. The results of the study suggest the high efficiency of citrate therapy in patients with ureteral stones in case of unobstructed urine outflow (including those with stents), which is comparable to surgical treatment.

[Radio wave electrotherapy with a radiofrequency of 448 khz for the treatment of patients with organic erectile dysfunction: a prospective, randomized, blind, Sham-controlled, parallel-group study]

AIM

To evaluate the efficiency of radio wave electrotherapy (448 kHz) for the treatment of patients with organic erectile dysfunction (ED).

MATERIALS AND METHODS

A prospective, randomized, blind, sham- controlled clinical trial was carried out. Inclusion criteria were as following: 1) patients with 5 to 20 points on the IIEF-5 score; 2) patients with proven organic erectile dysfunction lasting at least 6 months; 3) patients with penile arterial insufficiency and/or venous insufficiency, confirmed by doppler study of penile vessels with pharmacological stimulation (peak systolic velocity (PSV) <25 cm/s, end-diastolic blood flow velocity (DPV) >5 cm/s, resistance index (IR) < 0.8). The participants were randomized into two groups (experimental and control) in a 1:1 ratio. The full treatment course lasted 9 weeks. Patients underwent an assessment of erectile function based on questionnaires (IIEF-5, SEP, Schramek), as well as Doppler ultrasound of the cavernous arteries before inclusion in the study as well as a after treatment.

RESULTS

The study included 61 men (experimental group [n=31], control group [n=30]. There was a significant difference in the IIEF-5 scores after treatment between the experimental group and the control group (19.5+/-3.2 vs. 15.1+/-5.4, p=0.017, respectively). Significant differences were also noted in mean total score of the SEP questionnaire: an increase to 3.6+/-1.0 in the treatment group compared to 2.4+/-1.1 in the control group (p=0.004). The results of the Schramek questionnaire also demonstrated a significant increase in the mean score in the experimental group compared to the control group: 4.2+/-0.6 vs. 3.2+/-1.0 (p=0.011). The response time to the drug and the detumescence time also significantly differed between the two groups: 11.9+/-4.0 min vs. 15.5+/-4.1 min, p=0.001 and 126.6+/-60.7 min vs. 66.2+/-40.9, p<0.001, respectively. Neither complications nor any adverse events were recorded during treatment or after its completion.

CONCLUSIONS

Radio wave electrotherapy with a radiofrequency of 448 kHz can improve the IIEF-5, SEP and Schramek scores, as well as the indicators of ultrasound Doppler ultrasonography in patients with organic ED. To assess the feasibility of this method in patients with organic ED of different stages, further studies are needed.

[Use of intelligent analysis in urology]

The main methods of intellectual analysis (IA) used in modern medicine are described in the review. The main areas for IA application in the healthcare are diagnostics, treatment, prognosis of the course and efficiency of treatment in various diseases. The IA is based on mathematical methods and algorithms. The basic concepts of IA along with examples of its use in urological practice are presented in the review.

[Retrograde intrarenal surgery using a 1.94 m superpulsed thulium fiber laser]

INTRODUCTION

surgical treatment of urinary stone disease plays an important role in urological practice. Stone fragmentation can be performed using various lithotripters, from which Holmium fiber laser (Ho: YAG) has currently taken the main place. According to the current literature, a superpulsed thulium fiber laser with a wavelength of 1.94 m and a maximum power output of 40 W showed in vitro higher efficiency compared to Ho: YAG, while having the same safety profile. The use of a thulium fiber laser with a pulse energy of 0.025-6 J and a high repetition rate (up to 1600 Hz) allows to most effectively perform stone dusting during retrograde intrarenal surgery (RIRS).

AIM

to improve the performance of RIRS using the 1.94m superpulsed thulium fiber laser.

MATERIALS AND METHODS

a total of 152 patients with renal stones who were treated during the period from February 2018 to July 2019 were included in the study. The analysis of the laser settings, their effect on retropulsion and visibility when performing RIRS using a superpulsed thulium fiber laser with a wavelength of 1.94 m and a maximum power output of 40 W, a peak power of 500 W, as well as an assessment of the stone-free rate the first postoperative day and 3 months after the procedure was done.

RESULTS

The most frequently used settings were as following: 0.5 J, 30 Hz, 15 W (No. 1), 0.15 J, 200 Hz, 30 W (No. 2), 0.8 J, 31.25 Hz, 25 W (No. 3), 0.8 J, 37.5 Hz, 30 W (No. 4). The statistical analysis of the influence of the settings on the quality of endoscopic imaging and retropulsion was carried out. In addition, the features of each settings were analyzed. The stone-free rate on the first postoperative day was evaluated using low-dose CT.

CONCLUSION

A superpulsed thulium fiber laser with a wavelength of 1.94 m and a maximum power of 500 W has shown high efficiency in clinical practice when performing RIRS, since it allows to have good endoscopic imaging, minimal retropulsion, and to perform stone dusting, which had a positive effect on the stone-free rate. Optimization of the settings of thulium fiber lithotripsy may improve the results of surgical treatment of urinary stone disease.

[Flexible ureteroscopy for lower pole renal stones: novel superpulse thulium (TM) fiber laser lithotripsy]

INTRODUCTION

The SuperPulse Thulium (Tm) fiber laser (wavelength of 1.94 m) has been recently introduced as a directed-energy source for urology. Preclinical studies have shown a significant potential of the SuperPulse Tm fiber laser (SP TFL) for lithotripsy. However, clinical reports of using SP TFL to treat urolithiasis are still few and limited. Of special interest are challenging cases, e.g., lower pole stones, when extreme deflection of the instrument is required.

OBJECTIVE

To evaluate the effectiveness of the SuperPulse Tm fiber laser in the management of lower pole small calyceal stones during flexible ureteroscopy (F-URS).

METHOD

s. The SuperPulse Tm fiber laser device (Urolase 2, IRE Polus, Fryazino, Russia) has been cleared for clinical use by the Ministry of Health of Russian Federation. Study protocol has been approved by the Ethical Review Committee. Between January 2018 and February 2019, 130 patients with kidney stones have undergone Thulium fiber laser lithotripsy during F-URS. We retrospectively analyzed 15 of this patients with a single radiopaque lower pole calculus that were included in the present study. Stone size, stone density, lithotripsy time (from the first to last footswitch press) and "lasering" (laser emission) time were measured. The SP TFL was used for stone disintegration with different settings in dusting and fragmentation modes (0.1 - 4J, 7-300Hz, 6-40W) via a fiber with a 200-m core diameter. Low dose CT scanning was performed on POD 90 to assess SFR.

RESULTS

Stone size ranged from 4 to 17 mm and stone density varied from 350 to 1459 HU. The average lithotripsy time was 12 min (3-30 min). The average "lasering" time was 1.3 min (0.4-2.5 min) and the mean hospital stay was 1.1+/-0.3 days. In all cases we reached the lower pole stone containing calyx with a laser fiber. The complication rates were evaluated by using the Clavien-Dindo grading system and did not exceed GII (6.6%). SFR on POD 90 was achieved in 86.6% of cases.

CONCLUSIONS

F-URS with SuperPulse Tm fiber laser is safe and effective option in the management of lower pole small calyceal stones. The possibility of using small laser fibers gives better instrument deflection which make possible to reach lower pole calyceal stones even with acute lower pole infundibulopelvic angle (IPA).

[Analysis of the learning curve in laparoscopic partial nephrectomy in patients with localized renal parenchymal lesions depending on the nephrometric score]

AIM

to analyze the learning curve of surgeons while performing laparoscopic partial nephrectomy in patients with localized renal parenchymal lesions by calculating the MIC (negative surgical margin, ischemia, and complications) index depending on tumor complexity according to the R.E.N.A.L. and PADUA nephrometric scores.

MATERIALS AND METHODS

the retrospective study included the results of laparoscopic partial nephrectomies in 320 patients with localized renal parenchymal lesions. The procedures were carried out by four surgeons from the Institute of Urology and Human Reproductive Health of FGAOU VO I.M. Sechenov First Moscow State Medical University, Moscow, Russia (EC-1; ESH-4; EB-7; ME-13) from January 2014 to June 2019. At baseline, all operators had experience of performing at least 30 laparoscopic interventions. In addition to the standard preoperative examination, a 3D virtual planning was carried out using the Amira 3D modeling program. In all cases, the nephrometric assessment of complexity was performed according to the R.E.N.A.L. and PADUA scores. The learning curve was assessed based on the results of operations based on the MIC index. All surgical interventions were divided into eras. In the era, 40 consecutive procedures for each operator were evaluated. Acquired skills were assessed over two eras.

RESULTS

The average age of patients, of which 191 (59.7%) were men, was 54.4+/-11.37 years. The average body mass index was 28.55+/-3.85 kg/m2, the absolute volume of kidney lesions was 26.72+/-43.72 cm3, the average Charlson comorbidity index was 1.46+/-1.29, the average R.E.N.A.L. and PADUA scores were 6.38+/-1.75 and 7.92+/-1.51, respectively, the average duration of procedure was 150.36+/-50.18 min, the average blood loss was 227.94+/-280.22 ml, the average time thermal ischemia was 13.28+/-7.82 min. Postoperative complications were seen in 36 (11.2%) cases, of which grade III and more according to Clavien-Dindo developed in 8 patients (2.5%). A positive surgical margin was found in 4 (1.2%) patients. The overall MIC index was achieved in 243 (75.9%) cases; in era 1 it was seen in 71.9% cases in comparison with 80% in era 2. With the 1st degree of complexity (152 (47.5%) patients), MIC was achieved in 80.9% of cases, compared to 76.6% and 56.8% in patients with 2nd degree of complexity (n=124, 38.8%) and 3rd degree of complexity (n=44, 13.8%), respectively. Rate of MIC achievement in eras 1 and 2 for different surgeons were as following: 65% and 72.5%, 75 and 80%, 87.5 and 85% and 60 and 82.5%, for operator 1, 4, 7 and 13, respectively. Age, tumor complexity, R.E.N.A.L. score and PADUA score were the most significant parameters for determining MIC, identified on the basis of the criterion of equality of group means of discrete analysis.

CONCLUSION

In all surgeons, the MIC index increased with the accumulation of experience in performing laparoscopic partial nephrectomy, but was lower with an increased degree of complexity of procedures. The minimum number of laparoscopic partial nephrectomies required to achieve an MIC more or equal 70% should be at least 40.

[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.

[Ultrastructural characteristics of the mechanisms of varicose transformation of veins of different localization]

The contemporary interpretation of the pathogenesis of varicose vein transformation in young patients indicates the genetically determined pattern of this process. According to the diagnostic criteria proposed by T.I. Kadurina, varicose veins of different localization belong to the so-called minor phenomena of undifferentiated connective tissue dysplasia (UCTD) syndrome. However, its impact on the development of varicose vein transformation is taken into account by not all researchers probably due to the fact that its clinical manifestations remain somewhat unclear.

OBJECTIVE

To prove the role of UCTD syndrome in the development of varicose transformation of veins, by examining their wall biopsy specimens at the ultrastructural level.

MATERIAL AND METHODS

Vein wall fragments removed from 25 male patients were examined; their mean age was 19 years. All the patients were divided into 3 groups: 1) cases of left-sided varicocele (VC), 2) those of varicose veins in the lower extremities (VVLE), 3) control cases. Electron microscopy examination (EME) and morphometric and statistical analyses were performed.

RESULTS AND DISCUSSION

EME showed similar changes in the vein wall biopsy specimens obtained from both pediatric and adult patients with VC and VVLE. Analysis of the qualitative parameters of collagen fiber bundles revealed considerable differences in their thickness compared to those in the control group; the phenomenon of structural chaos; variability of their number in the bundles; uneven bundle thickness; abruptness of individual fibers due to their tortuous course; bundle disorganization areas and an expanded part of interfiber spaces. Morphometric analysis demonstrated a pronounced variability of numerical series when measuring their bundle thickness. The above changes indicate primary incompetence of the connective tissue framework of the varicose vein walls. The measurements of smooth muscle cells showed a decrease in their volume compared to that in the control group; there was an excessive proliferation of connective tissue between them. No substantial difference was found in the arithmetic mean of the measurements in different degrees of VC and VVLE and in the age groups for these diseases.

CONCLUSION

The ultrastructural analysis and morphometric results confirm the key role of UCTD syndrome in the pathogenesis of VC and VVLE and make it possible to combine these diseases into one - systemic varicose veins.

[Aberrant expression of arrestin-1 and recoverin in kidney tumors]

INTRODUCTION

Early diagnosis of renal cell carcinoma (RCC) is extremely difficult, due to the late development of clinical manifestations. The study of the aberrant expression of tumor-associated antigens and a production of autoantibodies to these proteins seems promising and novel method for RCC diagnosis.

AIM

To evaluate the possibility of using arrestin-1 (Arr-1), recoverin (Rec) and autoantibodies against arrestin-1 (AAA1) and recoverin (AAR) as a kidney tumor biomarker.

MATERIALS AND METHODS

Primary kidney tumors and metastases of 62 patients were investigated. For immunohistochemical studies, tissues were incubated with polyclonal antibodies against Rec and Arr1 as the main antibodies. Detection of AAR and AAA-1 in the serum of patients was performed using Western Blot analysis according to a standard protocol.

RESULTS

Among 62 tumors, renal cell carcinoma (RCC) constitutes 50 cases (86.4%), and oncocytoma was diagnosed in 12 patients (19.4%). In 11 (22%) cases of RCC, distant metastases were detected. Positive expression of Rec was observed in almost 71% of all types of kidney tumors. In 61.3% of patients with RCC, Arr-1 expression was seen. In the serum, AAR was found only in 1 patient (1.6%) with RCC. However, unlike AAR, AAA-1 in the serum of patients was observed much more often (75.8%).

CONCLUSION

According to our data, the presence of AAA1 in the serum, unlike AAR, can be considered as an early kidney tumor biomarker. The high expression of recoverin and arrestin-1 in kidney tumors suggests the use of these proteins in future as a marker for the diagnosis or even as a potential target for immunotherapy.

[Delayed ejaculation: epidemiology, diagnostics and treatment]

Delayed ejaculation is a form of sexual disorders, which is characterized by constant or intermittent delays or absence of ejaculation and orgasm, despite normal sexual arousal and erectile function. Delayed ejaculation is one of the most studied and rare types of male sexual dysfunctions, which leads to depression, anxiety, and often is a reason of low self-esteem, reduced satisfaction of a man with his partner, and worsening of relationships between partners. In some cases, delayed ejaculation and anejaculation cause infertility. Current views on epidemiology, diagnostics and treatment strategy of delayed ejaculation are presented in the article.

[Dual-energy computed tomography in the diagnostics of urolithiasis]

THE AIM

To assess the diagnostic performance of dual-energy computed tomography (DECT) in the evaluation of the composition of urinary stones "in vivo".

MATERIALS AND METHODS

A total of 91 patients aged from 20 to 70 years old (mean 42.7) with urinary stone disease were examined at Sechenov University, including 68 men (75%) and 23 women (25%). Prior to surgery, all patients underwent DECT (Canon, Japan) in order to predict the chemical composition of urinary stones in vivo. Extracorporeal shockwave lithotripsy (ESWL), percutaneous nephrolithotomy (PCNL) and ureteroscopy (URS) was performed in 53 (58.2%), 18 (19.7%) and 20 (22.1%) patients, respectively. Postoperatively, all stones or stone fragments (n=91; 100%) were examined using a comprehensive physical and chemical analysis (X-ray phase analysis, electron microscopy, infrared spectroscopy).

RESULTS

In 6 patients (6.6%) staghorn stones were diagnosed, while in 15 (16.5%), 17 (18.7%), 22 (24.2%) and 31 (34.1%) stones were located in ureteropelvic junction, pelvis and ureter, respectively, including 24 patients with lower ureteric stones (26.4%). Prediction of the stone composition in vivo was carried out on the basis of the one indicator, the dual energy ratio (DER). The threshold values of DER for different types of stones were taken from the literature. All stones were divided into 4 groups according to the DECT results: vevellite stones (n=40, 43.9%), Ca-containing stones without vevellite (n=34, 37.3%), uric acid stones (n=10, 10.9%) and struvite stones (n=7, 7.9%). Thus, when comparing the results of DECT and physical and chemical analysis, in the first group four stones were incorrectly assigned by DECT to the group of Ca-containing stones without vevellite and three stones were incorrectly assigned to the group of struvite stones; in the second group four stones were incorrectly assigned to the group of vevellite stones; in the third group one stone was incorrectly assigned to the group of struvite stones; in the fourth group one stone was incorrectly assigned to the group of vevellite stones and one stone in the group of uric acid stones. In order to increase the diagnostic efficiency of DECT, we performed a comprehensive analysis of five specific DECT indicators (stone density at 135 kV, Z eff of the stone, DER, DEI, DED) using discriminant analysis. Thus, the sensitivity, specificity and overall accuracy of DECT with the use of just one indicator (DER) were 83.3%, 89.8%, 86.8% for vevellite, 88.2%, 92.9%, 91.2% for Ca-containing stones without vevellite, 90%, 98.8%, 97.8% for uric acid stones and 60%, 95.3%, 93.4% for struvite stones, respectively. When using discriminant analysis with five specific DECT indicators, higher values of sensitivity, specificity and overall accuracy were seen: 95.2%, 89.8%, 92.3% for a vevellite, 85,3%, 96,4%, 92,3% for Ca-containing stones without a vevellite and 100%, 100% and 100% for both uric acid and struvite stones, respectively.

CONCLUSIONS

Dual-energy computed tomography is a highly informative method which allows to perform preoperatively the reliable assessment of the chemical composition. DECT in patients with urinary stone disease allows to optimize the treatment strategy and carry out preventive measures on individual basis, taking into account the stone type.

[Venous wall weackness pathogenesis in varicose vein disease]

Varicose veins of lower extremities, varicocele and varicose dilation of pelvic veins including ovaricovaricocele are the most common non-inflammatory diseases of venous system. The same mechanisms determined varicose dilatation regardless localization of the vein. First of all, these are wall weakness and valvular insufficiency combined with hereditary collagen fiber defectiveness in case of undifferentiated connective tissue syndrome. Imbalance between different types of collagen in vascular wall (especially types I and III) also results wall weakness. Other important mechanisms are smooth muscle cells dysfunction followed by excessive intracellular synthesis and intramuscular fibrosis and imbalance of protease system due to overproduction of metalloproteinases. We consider that different forms of varicose veins (varicose veins of lower extremities, varicocele, ovaricovaricocele) may be unified within one pathology (varicose vein disease).

[Multidisciplinary approach in urology. Laser technologies: faster, simpler, more efficient]

Laser technology has taken a place among the methods of treatment of various urological diseases. The new laser devices are being developed in addition to commonly used. Physicists of the russian NTO "IRE Polus" in collaboration with doctors from Sechenov University have developed a new generation laser device - thulium fiber laser. It has been actively used since 2017 for laser enucleation of prostate. Later the laser was used for treatment of bladder tumor, lithotripsy. The device has already managed to prove its efficacy in in-vitro experiments and clinical practice surpassing foreign analogues.

[Novel approaches for transurethral en-bloc resection of large bladder tumors]

OBJECTIVE

to develop optimal techniques of en-bloc resection of large non-muscle invasive bladder tumors, determine the proper method of specimen extraction and assess the quality of specimens obtained by different techniques.

MATERIALS AND METHODS

A total of 12 patients with primary cT1 bladder cancer underwent transurethral en-bloc resection between January 2018 and March 2019 were enrolled into the study. Tumor size ranged from 3.5 cm to 6.2 cm. For removal and extraction of large bladder tumors using thulium fiber en-bloc laser three different techniques were developed: "swiss cheese technique", "crown and root technique" and "three steps technique" technique". The main pathologic criteria used for assessment of removal technique were tumor grade (G), depth of invasion (T), presence of carcinoma in situ (CIS), variant histology (VH), lymphovascular invasion (LVI), presence of detrusor muscle. Additional criteria were horizontal and vertical resection margin, subclassification of T1-stage and presence of focal necrosis in tumor.

RESULTS

Among the techniques developed and tested, the best quality of specimens for morphological evaluation was obtained using the combined "crown and root technique". First step is electroresection of the exophytic part of the tumor into pieces, and the next step is en-bloc laser resection (using thulium fiber or holmium laser) of the tumor base. Overall, the quality of all specimens obtained using three techniques met the current requirements of pathologic study.

SUMMARY

En-bloc resection techniques of large bladder tumors allow obtaining specimen suitable for proper morphological evaluation and correct tumor staging. Further studies are required to evaluate the impact of these techniques on long-term results of treatment options.

[Clinical value of herbal terpenes after extracorporeal shock-wave therapy]

BACKGROUND

Rowatinex is a combined drug based on plant terpenes which provides diuretic, anti-inflammatory and antispasmodic effect. A use of herbal preparation Rowatinex in patients with urinary stone disease after extracorporeal shock-wave therapy (ESWL) is analyzed in the article.

AIM

To clarify the efficiency of the drug Rowatinex in patients with urinary stone disease after ESWL.

MATERIALS AND METHODS

All patients were divided into two groups depending on therapy administered after ESWL. In main group (n=150) patients received Rowatinex, while in control group (n=70), antispasmodics were administered. Spontaneous passage of fragments was observed in 104 patients in main group (69.3%) and 30 patients in control group (42.9%).

RESULTS

When studying the effect of therapy on the changes of complete blood count, biochemical panel and daily excretion of some substances (magnesium, uric acid, calcium, etc) there were no significant differences between main group and control group. All values were normal. It was estimated that increase in diuresis during use of Rowatinex contributes to effective and rapid passage of stone fragments. In addition, there was a decrease in leukocyturia in both groups.

CONCLUSION

Drug Rowatinex allows to reduce the time to spontaneous passage of fragments after ESWL, intensity of pain syndrome and leukocyturia as well as to increase in daily diuresis. This is not accompanied by the development of complications and side effects which allows to administer Rowatinex for a long time as part of complex medical expulsive therapy and use it for recurrence prevention of urinary stone disease. Effect of Rowatinex didnt depend on the stone composition.

[Markers of stem cells and their prognostic values for urothelial carcinomas of the urinary tract]

The fundamental question about the origin of cancer stem cells of urothelial carcinomas with luminal remains open. So far, no convincing evidence has been found to determine whether these events occur in a single cell, presumably basal, or are realized in different precursor cells of the urothelium. The potential of a number of potential stem markers as cancer stem cells in urothelial carcinomas and their prognostic significance are currently being investigated.

AIM

Our aim was to carry out a comparative analysis of the expression of stem markers in the molecular subtypes of urothelial carcinomas, including ALDH1A1, CXCR4, CD24, CD82, CD105, CD133, NANOG, OCT4 and SOX-2. In addition, the relationship between the pattern of expression and the pathological features of the tumor was determined.

PATIENTS AND METHODS

Surgical specimens from 196 patients with a diagnosis of urothelial carcinoma of the renal pelvis and bladder were studied. Immunohistochemical study was performed on paraffin sections using the standard protocol. Antibodies against ALDH1A1, CD82, CD133, CXCR4, NANOG, OCT4, SOX2 ("Abcam"), CD24, CD105 ("Invitrogen"), CD31, CD34 ("Novocastra") were used.

RESULTS

The stem cell markers used in the study were expressed in all molecular subtypes of urothelial carcinoma and there were no differences in frequency and intensity of expression between different phenotypes. However, the frequency and intensity of expression of the markers correlated with the tumor stage and the grade of cellular anaplasia.

CONCLUSION

Our results confirm that cancer stem cells with basal phenotype are not an exclusive subpopulation in urothelial tumors. Other progenitor cells with the immunophenotype of intermediate and/or umbrella cells can serve as cancer stem cells. These features of the expression in cancer stem cell markers will allow to develop new approaches to the treatment of urothelial carcinomas.

[Molecular basis of intratumoral heterogeneity of urinary tract urothelial carcinoma]

In the article the main mechanisms of molecular pathogenesis of urinary tract urothelial carcinoma are presented. Two different molecular pathways that determine the development of non-invasive and invasive urothelial carcinoma, the immunohistochemical spectrum of stem markers and aspects of the carcinogenesis of multifocal and recurrent tumors are considered.

[Zero-ischemia nephron-sparing interventions for renal tumor. do we need 3D-modeling?]

INTRODUCTION

our aim was to assess and compare a zero ischemia enucleation and enucleoresection of tumor, as well as classical partial nephrectomy. In addition, we defined a role of a three-dimensional reconstruction of the tumor for the planning of intervention.

MATERIALS AND METHODS

a total of 83 patients with localized renal tumors were included in the study. There were 48 men (57.8%) and 35 women (42.2%), with mean age 56.8+/-11.9 years. The patients were divided into 3 groups depending on the type of intervention. The enucleation, enucleoresetion and classical partial nephrectomy with removal of 0.5-1 cm margin of normal parenchyma was performed in Group 1 (n=41), Group 2 (n=31) and Group 3 (n=11), respectively. A computer program Amira was used for the reconstruction of 3D-model of tumor during preoperative planning. On the basis of 3D-model, an information about the structures situated beneath the tumor was obtained, as well as anatomy of vessels and relationship between the renal pelvis system and the tumor.

RESULTS

In all cases the interventions were performed laparoscopically. Transperitoneal access was used in 34 (41%) cases, while retroperitoneal access was chosen in 49 patients (59%). The amount of blood loss was higher in 23 patients (27.7%) with tumors located in renal sinus (205.7+/-29.1 ml), than in patients with exophytic and endophytic tumors (142.3+/-15.2 and 208.2+/-35.9 ml, respectively; p=0.005). The duration of the surgery was less in those cases where parenchyma was under the bottom of the tumor, according to the 3D-model (58.3+/-6.8 min), compared to the patients with collecting system or vessels located under the tumor (87,6+/-5.2 min, p=0.005). The amount of blood loss was 179.4 +/- 41.8 ml in patients with one vessel located beneath the tumor, according to the 3D-model, in comparison with those cases with three vessels (360.0+/-87.2 ml). There was no need for clamping of the renal vessels or conversion to the open surgery. In the enucleation group, neither intraoperative nor postoperative complications were observed.

CONCLUSION

According to the results, we can conclude that 3D modeling undoubtedly gives clear advantages for the urologist during the planning of the intervention. Tumor enucleation seems to be the optimal method of partial nephrectomy, which allows to perform a dissection near to the renal sinus with the small risk of complications.

[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.

[Laser in laparoscopic urology]

Nowadays, various laparoscopic instruments for tissue dissection and vessel coagulation are available. However, there are ongoing studies dedicated to "ideal" type of energy suitable for this aim. Laser radiation has been used for many years in medical practice and it is established as reliable and effective method in surgical armamentarium. The ability to provide highly precision and well-controlled action on the tissues, improved hemostasis, easy adaptability to fiber-optic and minimally invasive delivery systems, as well as the possibility of facilitating complex dissection made lasers an important tool for surgeons. The mechanism and methods of laser energy using in urology have been studied since 1980s, but there is still no consensus on the optimal type of laser and its settings during urological surgeries, which determines the importance of further researches dedicated to this promising form of energy.

[A comparative analysis of laparoscopic and retroperitoneoscopic partial nephrectomy depending on the type of temporary and definite hemostasis]

AIM

to carry out a comparative analysis of treatment results of patients with renal tumors who were undergone to nephron-sparing surgery, depending on the type of temporary and definite hemostasis.

MATERIALS AND METHODS

a total of 163 laparoscopic partial nephrectomies were performed by single surgeon from January 2015 to July 2018. The comparative analysis of treatment results of patients with renal tumors based on following parameters: tumor stage, features of the tumor site, the duration of surgery, the amount of blood loss, complications rate and grade as well as functional and oncological outcomes, depending on the type of temporary and definite hemostasis, was conducted. For preoperative planning the generally accepted nephrometric scale R.E.N.A.L. was used as well as 3D-reconstruction of the tumor.

RESULTS

Of the 163 patients, 64 were women (39.3%). The mean age of patients was 56.7+/-11.1 (25-80 years). A clinical stage T1a, T1b, T2 and T3a was diagnosed in 77, 20, 2 and 64 cases, respectively. The average tumor size was 34.8+/-1.1 (11-78 mm). The mean operative time was 84.5+/-32.2 min (30-180). Laparoscopic transperitoneal access was used in 90 patients (55.21%), retroperitoneoscopic approach was chosen in 73 cases (44.79%). The tumor had exophytic growth in 110 cases (67.5%) and in 53 cases it was endophytic (32.5%), while in 59 cases it localized in renal sinus (36.2%). The operative time was significantly shorter in the Group of zero ischemia (72.2+/-29.02 [p<0.001]) and bipolar coagulation of the tumor bed (60.8+/-31.7 [p<0.001]). The mean volume of blood loss was 160.8+/-142.7 ml (30-900). A GFR calculated by the MDRD equation (mean level was 75.7 ml/min/1.73 m2) on the next day and 6 months after surgery showed a slight decrease in group of zero ischemia, compared to other groups: next day and 6 months after surgery it was 72.8+/-21.6 (p<0.001) and 72.01+/-16.6 (p=0.025), respectively. A simple enucleation was performed in 41 cases, while enucleoresection was done in 70 cases. A collection system was opened in 22 cases (13.5%+/-9.8). The suturing and clipping were performed in 20 and 2 patients, respectively. In 2 cases a stenting was performed. In 2 cases there was hemoglobin drop requiring blood transfusion (1.2%+/-3). An embolization due to refractory bleeding was required in 3 cases (1.8%+/-3.7). There was no conversion to open surgery or nephrectomy. Of the 163 tumors, a malignancy was diagnosed in 151 (92.6%+/-7.5) cases. There was no positive surgical margin and recurrence of the tumor.

CONCLUSION

Laparoscopic partial nephrectomy can be successfully performed under zero ischemia. The intervention without clamping of renal blood vessels contributes to significant preservation of the renal function.

[Current trends in bladder cancer diagnosis]

In the Russian Federation, a proportion of bladder cancer in the overall structure of malignant tumors is about 2.8% and among oncological diseases of genitourinary system its incidence is second only to prostate cancer. Bladder cancer ranks as ninth most prevalent in males and as eighteens in females. The most important issue is to determine a recurrence rate of non-muscle invasive bladder cancer, which can reach 80%. In this regard, currently, all over the world much more attention is paid to studying and creation of early detection, including non-invasive, which will be reliable in the early stages. It can possibly lead to a reduction the number of cystoscopy and become as "golden" standard of non-invasive diagnosis bladder cancer.

[Urate urolithiasis: pathogenesis and possibilities of conservative therapy]

Urolithiasis is a widespread chronic disease; its prevalence has been steadily increasing over the past 50 years. Urolithiasis accounts for a large proportion urologic diseases, exceeded only by urinary tract infections and diseases of the prostate. Urate urolithiasis refers to a type of urolithiasis, characterized by the formation of kidney stones consisting of uric acid or its salts. In populations of industrialized countries, uric acid is the second or third most frequently occurring stone-forming substance. The article summarizes the data on the global prevalence of both urolithiasis as a whole and urate urolithiasis in particular. The authors provide a detailed overview of the formation of the current concept of the urate urolithiasis pathogenesis and the management of the disease. The main focus is placed on the possibilities and the role of litholytic (stone-dissolving) therapy for urate urolithiasis and the mechanisms of the action of citrate preparations.

[Experimental verification of thulium lithotripsy]

AIM

Experimental evaluation of the efficacy and safety of lithotripsy using a new pulsed thulium fiber laser operating at a wavelength of 1.94 microns, peak power of 500 watts (maximum average power of 50 watts) by comparing it with a holmium laser operating at a wavelength of 2.1 microns (average maximum power 100 W and 120 W).

RELEVANCE

The proportion of minimally invasive surgery in the management of urolithiasis, including retrograde intrarenal surgery, is steadily growing. The most appropriate tool for stone destruction is a laser. To date, the gold standard of minimally invasive surgical treatment of nephrolithiasis is holmium laser lithotripsy, which uses a laser on yttrium-aluminum-garnet activated by holmium ions (Ho: YAG) operating at a wavelength of 2.1 m. However, in recent years, lasers on a Tm-activated fiber with a wavelength of 1.94 m have become increasingly popular since the water absorption coefficient for the Tm radiation of a fiber laser is 5.5 times higher than for a Ho: YAG laser and in 2.2 times higher than for the Tm: YAG laser. This difference may translate into greater effectiveness and speed of stone crushing, which in turn leads to shorter operating time.

MATERIALS AND METHODS

This article describes physical foundations of holmium and thulium laser radiation, the mechanisms of stone fragmentation, data from a series of experiments comparing the efficiency and safety of ex-vivo lithotripsy using a holmium solid-state laser with a wavelength of 2.1 m and a thulium fiber laser with a wavelength of 1.94 m.

RESULTS

The study findings suggest that the STA IRE-Polyus thulium fiber laser operating at a wavelength of 1.94 microns and a maximum power of 500 watts has several advantages over the holmium laser in the stone fragmentation in urological practice.

CONCLUSION

The results of the experimental work allow us to conclude that the use of a thulium fiber laser operating at a wavelength of 1.94 m and a maximum peak power of 500 W enables highly effective and safe lithotripsy.

[Genetic factors for monogenic forms of calcium urolithiasis]

The article presents pooled results of domestic and international studies investigating genetic aspects of urolithiasis associated with impaired calcium metabolism. The review highlights the importance of early and accurate diagnosis of hereditary diseases associated with kidney stone formation. Of more than 80 currently known monogenic forms of urolithiasis, the authors provide the list of the most significant forms. Using such molecular genetic methods as NGS (next generation sequencing) allows accurate detection of the genetic cause of the disease, develop an individual approach the patients management and timely prevention of the disease among the relatives of the proband.

[Urinary bladder reconstruction using a free revascularized musculo-cutaneous thoracodorsal autograft. A case report]

The article presents a rare case of urinary bladder reconstruction using thoracodorsal revascularized autograft in a patient with a bladder injury resulting from a road traffic accident. The area and size of the thoracodorsal flap (2215 cm) were determined using a 500 ml latex model of the bladder. The autograft was revascularized through external iliac vessels. From the thoracodorsal autograft, the dome was formed with the dermal part inward, which was fixed along its circumference to the bladder edges with 3/0 prolene sutures. The muscular part of the thoracodorsal flap was fixed along the perimeter to the remaining aponeurosis and covered by a free expanded cutaneous autograft. The surgery resulted in a newly constructed neobladder of sufficient volume (250-300 ml) with elements of the patients own bladder (posterior wall and neck) while sparing the patient from a cystostomy and improving his quality of life.

[En bloc holmium laser enucleation of the prostate (HOLEP EN BLOC): our experience]

INTRODUCTION

Some authors consider HoLEP a new gold standard for the surgical management of prostatic hyperplasia. The increasing utilization of holmium enucleation has led to the development of various modifications of this treatment modality, including the so-called enucleation as a single piece (HoLEP en bloc), which reduces the operative time and, according to some authors, facilitates acquiring new surgical technique by surgical trainees.

AIM

To compare the effectiveness and safety of the traditional HoLEP and HoLEP en bloc.

MATERIALS AND METHODS

The study comprised 227 BPH patients aged from 53 to 86 years old (mean - 61.38+/-5.09 years). HoLEP en bloc was performed in 114 patients, of whom 39 patients had prostate volume (Vpr) less than 80 cm3, and in 75 patients it was more than 80 cm3. The standard HoLEP was performed in 113 patients, of whom 41 patients had Vpr less than 80 cm3, and in 72 patients it was more than 80 cm3.

RESULTS

Enucleation time: HoLEP - 48+/-12 min, HoLEP en-bloc - 35+/-10; morcellation time: HoLEP - 20+/-3 min, HoLEP en-bloc - 16+/-12; duration of urinary bladder drainage by a urethral catheter: HoLEP - 58+/-3 h, HoLEP en-bloc - 41+/-2; length of hospital stay: HoLEP - 5.93+/-0.39 days, HoLEP en-bloc - 4.45+/-0.35; bladder tamponade, urethrocystoscopy and coagulation of bleeding vessels: HoLEP-3, HoLEP en-bloc-1; infectious-inflammatory complications (prostatitis): HoLEP-3, HoLEP en-bloc-2; acute urinary retention, stress urinary incontinence: HoLEP-6, HoLEP en-bloc-2; stress urinary incontinence: HoLEP - 5, HoLEP en-bloc - 2.

CONCLUSION

En bloc holmium enucleation of the prostate results in the reduction of enucleation and total operative time compared with traditional HoLEP due to the fast identification of the surgical capsule and the right layer. Using this technique can improve the effectiveness of learning holmium laser enucleation of the prostate by surgical trainees.

[Issues of spectrum and local sensitivity of E. coli in female patients with acute uncomplicated lower urinary tract infection a review of M. Seitz study and own observations]

RELEVANCE

Acute uncomplicated lower urinary tract infections (AULUTI) are one of the most common diseases in urological practice. The management of cystitis is commonly based on antibacterial therapy. Despite the high efficiency, inadequate prescription of antibiotics leads to an increase in microorganisms resistance. In light of these matters, the selection of antibacterial agents to which the sensitivity of bacteria is the highest is becoming increasingly challenging.

AIM

To estimate the spectrum and local sensitivity of E. coli in patients with AULUTI.

MATERIALS AND METHODS

The present study analyzed the results of bacterial culture sampled from 45 patients with AULUTI. The mean age of the patients was 44+/-17 years. All bacterial cultures were obtained in out-patient settings in the framework of a multicenter initiative study on the prevention of recurrent AULUTI with d-mannose.

RESULTS

Microbiological studies of the urine of patients with AULUTI revealed the growth of E. coli in concentrations ranging from 104 to 107 CFU/ml. Assessment of sensitivity demonstrated 100% sensitivity of Escherichia coli to fosfomycin trometamol.

CONCLUSION

According to the findings of microbiological studies, the patients with the AULUTI retain the highest sensitivity level of E.coli to phosphomycin trometamol, which allows it to be used as a first-line drug.

[En-bloc laser resection of the urinary bladder tumor]

Currently, transurethral resection of a bladder tumor (TUR) is the gold standart treatment for non-muscle invasive bladder cancer (NMIBC). Standard TUR for a bladder wall tumor has a high recurrence rate, which is caused mainly by malignant cell implantation during the surgery. Besides, specimens obtained with conventional TUR are insufficient for accurate pathological staging. The non-conformity of the standard TUR with the established oncological principle of dissecting through normal tissue prompted a search for the optimal surgical modality. En-bloc resection of the bladder wall tumor has been proposed as an alternative method for surgical management of NMIBC. This technique involves the resection of bladder tumor through the underlying muscle layer as a single piece thus providing high quality material for subsequent morphological study and reducing the risk of metastasizing by implantation of malignant cells. This paper presents an analysis of relevant research literature published in the last twenty years, describes all currently existing techniques of the bladder tumor resection using a variety of energy sources, including laser.

[Results of a comparative multi-center randomized clinical study of efficacy and safety of EFFEX Tribulus and Tribestan in patients with erectile dysfunction]

RELEVANCE

Erectile dysfunction (ED) is a common condition. Pharmacological management of ED involves medications produced by chemical synthesis. Despite high efficiency, their use is often accompanied by some side effects. Considering this, herbal preparations with sufficient efficacy and greater safety have received much attention.

AIM

To compare the efficacy and safety of two herbal preparations (EFFEX Tribulus and Tribestan) based on Tribulus Terrestris herb dry extract in patients with ED.

MATERIALS AND METHODS

A total of 173 patients were enrolled in the study, of whom 87 (group I) and 86 (group II) received EFFEX Tribulus and Tribestan, respectively. The mean age of patients was 42.2+/-11.5 years in group I and 42.8+/-11.2 years in group II. One hundred fifty two patients completed the study. The follow-up was 13 weeks (the herbal preparation dose was titrated at week five after the treatment initiation). The effectiveness of treatment was assessed on five follow-up visits using the IIEF, AMS, MSF, GAQ questionnaires, and a complex of diagnostic and laboratory studies.

RESULTS

At visit five compared to visit 1, the mean IIEF erectile function domain score increased by 5.7+/-4.6 and 5.2+/-4.3 points in group I and II, respectively. In both groups, all other IIEF domain scores demonstrated a statistically significant increase. The AMS scores decreased from 32.93+/-10.04 to 25.02+/-7.62 points in group I and 31.78+/-10.37 to 24.55+/-7.31 points in group II. The SMF scores increased from 22.36+/-4.85 to 27.16+/-4.80 points in group I and from 22.13+/-3.69 to 26.10+/-5.69 points in group II. Besides, the use of the herbal preparations was associated with a decrease in the serum cholesterol level, more pronounced with increasing patient age (correlation coefficient -0.06, p=0.41).

CONCLUSION

The herbal preparations EFFEX Tribulus and Tribestan have a similar efficacy and safety profiles.

[Endoscopic enucleation of the prostate: a short term trend or a new treatment standard?]

Endoscopic enucleation of the prostate (EEP) techniques such as HoLEP (holmium laser enucleation of the prostate), ThuLEP (thulium laser enucleation of the prostate) and electroenucleation (mono- or bipolar) are highly effective and safe. They have been endorsed by the latest version of the European Association of Urology guidelines as an alternative to not only open adenomectomy but also transurethral resection of the prostate (EAU Guidelines on Treatment of Non-neurogenic Male LUTS 2018). Therefore, many urologists face the possibility of replacing the treatments of BPH. In this article, we analyze the history of EEP techniques, both their pros and cons and, what are they today - just a popular trend or a new standard procedure for the surgical treatment of BPH?

[Current view on the pathogenesis of varicocele and the problem of its recurrence]

The clinical signs of varicocele typically emerge during the puberty. Varicocele is found in 15% of men in the general population and 25-35% and 50-80% of males presenting with primary and secondary infertility, respectively. Factors contributing to the development and recurrence of varicocele include the abnormalities of the testicular venous drainage and outflow (varicose veins are more common on the left than on the right), the anatomical features of the veins of the testicular and prostatic venous plexus, the patients constitution, predisposition to constipation or diarrhea, physical activity. At present, the genetic defects, including the undifferentiated connective tissue dysplasia (UCTD) with hereditary insufficiency of venous valves and the weakness of the testicular vein walls, are thought to play a key role in the formation of a varicocele. Considering the importance of varicocele in the development of male infertility, the role of the UCTD in varicocele formation warrants a detailed investigation to provide an individual approach to patients and predict the disease recurrence.

[Comparative analysis of the effectiveness of various techniques of endoscopic prostate enucleation in a single center]

AIM

To compare electro- and laser enucleation (thulium, holmium) of prostate hyperplasia.

MATERIAL AND METHODS

693 prostate hyperplasia patients were enrolled. 489 patients underwent holmium enucleation (HoLEP), 51 - monopolar enucleation, 153 - thulium enucleation (ThuLEP). Prostate volume was 91.7 (50-250) cm³. There were no significant differences in preoperative variables between both groups (I-PSS, QoL, Qmax, residual urine volume) (p>0.05).

RESULTS

Mean time of HoLEP was 97.0±42.2 min, monopolar enucleation - 112.9±36.3 min, ThuLEP duration was significantly less (77.4±36.3 min, p<0.01). An efficacy of all methods was confirmed in 6 months after surgery by significant (p<0.01) improvement of functional parameters (I-PSS, QoL, Qmax, residual urine volume).

CONCLUSION

High efficiency of thulium and holmium enucleation allows to consider them as 'gold standard' of prostate hyperplasia management. Despite higher incidence of complications an efficacy of monopolar enucleation is comparable to that in laser techniques.

[Laparoscopic pyelolithotomy and its role in modern surgery of nephrolithiasis]

AIM

To determine the place of laparoscopic pyelolithotomy in surgical management of nephrolithiasis.

MATERIALS AND METHODS

We analyzed 16 laparoscopic pyelolithotomies performed in our clinic over the last few years for large and stag-horn stones of anomalous kidneys (n=8), the "giant" (>30-40 cc) monolithic stones of the large extrarenal pelvis (n=3), multiple stones of PCS with the stone burden of more or equal 40 cm (n=2) and large recurrent (after PCNL) kidney stones in patients at risk of bacteriotoxic complications of percutaneous nephroscopy (n=3). The age of the patients ranged from 39 to 72 years (mean age 51+/-8 years). The average density of stones was 1012 (160-1483) HU.

RESULTS

There were no conversions to open surgery. The mean operating time of laparoscopic pyelolithotomy was 137 (96-255) minutes, flexible transabdominal pyelocalycoscopy 31.2 (12-110) min. The stone-free rate was 87%. Residual clinically insignificant stones were found in two (13%) patients with staghorn horseshoe kidney calculi and complex PCS. The preoperative hospital stay was 1 day, postoperative-from 2 to 18 (mean 6) days.

DISCUSSION

We believe that laparoscopic pyelolithotomy supplemented by transabdominal flexible pyelocalycoscopy may be recommended for surgical management of patients with "giant", multiple and infected kidney stones, because the length of their percutaneous removal is beyond the recommended time intervals and it is accompanied by an increased risk of septic complications.

[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.

[Laser enucleation of the prostate (HOLEP and THULEP): a comparative effectiveness analysis in treating recurrent prostatic hyperplasia]

INTRODUCTION

The estimated recurrence rate of benign prostatic hyperplasia (BPH) after transurethral resection of the prostate is about 5 to 15%. Laser enucleation of the prostate results in a much lower recurrence rate (not exceeding 1-1.5%). At the same time, laser enucleation of the prostate is still not widely used for recurrent prostatic hyperplasia since it believed to be technically difficult in cases.

AIM

To describe the distinctive features of thulium and holmium laser enucleations of the prostate in the management of recurrent BPH and show that the technical difficulties are not an obstacle to the wide application of this technique.

MATERIALS AND METHODS

This was a retrospective study comprising 676 patients aged 54 to 87 years with clinically pronounced infravesical obstruction due to prostatic hyperplasia (IPSS>20, Qmax<10). All patients were divided into four groups. Groups 1 (n=489) and 3 (n=153) underwent holmium (HoLEP) and thulium (ThuLEP) laser enucleations of the prostate, respectively. Groups 2 (n=23) and 4 (n=11) included patients with BPH recurrence after HoLEP (group 2) and ThuLEP (group 4). All patients underwent diagnostic evaluation at baseline and at 6 months after surgery.

RESULTS

The mean ThuLEP operating time was shorter than that of HoLEP (p=0.02). The mean duration of repeat and primary ThuLEP and HoLEP did not differ statistically significantly (p>0.05). There was no difference in the length of hospitalization and catheterization between the four groups (p>0.05). At six months after surgery, a statistically significant improvement in I-PSS, Qmax, QoL, and RUV was observed in all groups compared with preoperative values (p>0.05)).

CONCLUSION

We found that the technical difficulties of the re-operation, such as the difficult separation of adenomatous tissue from the prostate capsule, the multinodular nature of the adenoma, increased tissue density are easy to overcome and do not confer a significant complexity. In turn, better completeness of resection, low complication and recurrence rates and the possibility of surgery, even in elderly patients with multiple comorbidities - these features allow us to conclude that laser enucleation of the prostate is not only an effective treatment for infravesical obstruction due to benign prostatic hyperplasia, but is also a method of choice in the treatment of patients with recurrent BPH.

[Ultrasound-guided percutaneous cryoablation of renal tumors]

INTRODUCTION

Surgery remains the gold-standard curative treatment for localized (T1) renal carcinoma. However, recent medical-technological advances have led to the development of new minimally invasive treatment options, one of which is percutaneous cryoablation.

AIM

To assess the effectiveness and safety of ultrasound-guided percutaneous cryoablation of renal tumors.

MATERIALS AND METHODS

The study comprised 12 patients aged 52 to 76 years who underwent ultrasound-guided percutaneous cryoablation of renal tumors from 2015 to 2017. In 11 patients, the size of the renal mass was 3.0 cm (T1a), in 1 patient 4.5 cm (T1b). A Doppler ultrasound, contrast-enhanced MSCT and computer 3D modeling were performed in all patients pre-operatively and 6 months after surgery to assess the tumors size and extent and the spatial location of the tumor internal surface to the pelvicalyceal system. In all patients, the tumors were located along the posterior or lateral surface of the kidney, in the lower or middle segment and without sinus invasion. We used a 3rd generation Galil Medicals SeedNet Gold Cryotherapy System and IceSeed and IceRod cryoprobes. Intraoperatively, immediately before cryoablation, the tumor was biopsied. In all patients the diagnosis of renal cell carcinoma was confirmed morphologically.

RESULTS

Mean duration of cryoablation was 60 minutes. Endotracheal, spinal, local and intravenous anesthesia was used in 1, 6, 5 and 1 patients, respectively. Doppler ultrasound at 6 months after surgery showed that in 11 patients (T1a) the tumor size decreased on average by 8 mm, with no blood flow in the tumors. MSCT with 3D modeling also revealed a decrease in tumor size and total absence of contrast agent accumulation, or accumulation gradient not exceeding 10 HU (initially it was about 200 HU). In the patient with T1b stage renal carcinoma, MSCT showed a decrease in tumor size from 4.5 to 3.7 cm, however, there was a mass up to 1.5 cm with a high gradient of contrast agent accumulation. The patient underwent kidney resection. No intra- and postoperative complications were observed.

CONCLUSION

The accumulated experience allows to confirm the effectiveness and safety of ultrasound-guided percutaneous cryoablation and to consider it a method of choice for patients with stage T1a renal carcinoma located along the posterior or lateral surface of the kidney in the lower or middle segment, without sinus invasion.

[Current laser technologies for the surgical treatment of prostatic hyperplasia]

The first medical application of lasers dates back to the mid-60s of the XX century. Since then, laser systems have undergone significant changes. No longer a science fiction, lasers are used in many medical fields as an indispensable tool in the hands of the modern physician. The article outlines advances in laser techniques (from the idea of laser radiation to the modern laser systems used as effective surgical tools). We also present our experience in using laser surgical techniques in treating patients with prostatic hyperplasia.

[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.

[Endoscopic removal of papillary tumors of upper urinary tract]

AIM

To assess the results of organ-sparing endoscopic treatment of patients with tumors of the upper urinary tract (UUT).

MATERIALS AND METHODS

Twenty four patients underwent percutaneous and ureteropyeloscopic interventions for tumors of the upper urinary tract and were followed up at the Urology Clinic, I.M. Sechenov First MSMU. Retrograde removal of benign tumors of the renal pelvis and ureter (tumors sized from 5 to 35 mm), percutaneous removal of papillary carcinoma of renal pelvis of a solitary kidney, percutaneous removal of papillary carcinoma of renal pelvis of only one functioning kidney and percutaneous removal of papillary carcinoma of the lower calyx of the L-shaped kidney were performed in 21, 1, 1 and 1 patients, respectively. The patients had stage T1 papillary cancer of the upper urinary tract. There were 7 (29.2%) men and 17 (70.8%) women with mean age 64+/-5 years. Electroresection/vaporization was carried out in 18 patients, and 6 patients were treated using Holmium laser.

RESULTS

None of the endoscopic procedures required conversion to open surgery or a more extended surgical operation. There were no recurrences or impaired UUT urinary flow in patients with benign UUT tumors at different points of follow-up. In 3 cases of malignant UUT tumors no recurrences occurred during 12-20 months follow-up.

CONCLUSION

and discussion. Nephroureterectomy with resection of the urinary bladder is the standard radical treatment of patients with tumors of the UUT. Technological advances in endoscopic and percutaneous surgery for UUT have allowed for organ-sparing procedures in patients with neoplasms of pelvicalyceal system and ureter. The absolute indications for such organ-sparing operations now include solitary kidney or only one functioning kidney and chronic renal failure. Endoscopic resection of the tumor and renal pelvic wall within healthy tissue, including by holmium laser, with tumor stage not exceeding T1 and followed by trans-fistula chemotherapy can be regarded as an effective treatment for patients with tumors of pelvicalyceal system.

[Monopolar transurethral enucleation of benign prostatic hyperplasia. Our initial experience]

INTRODUCTION

The choice of surgical treatment in patients with BPH is one of the most discussed issues in urology. In recent years, the surgical treatment of prostates of medium and large sizes by means of enucleation has become increasingly popular.

OBJECTIVE

The emergence of special loops to perform bipolar and monopolar enucleation using standard equipment for TURP has opened up new possibilities for the treatment of patients with BPH-transurethral monopolar enucleation BPH.

PATIENTS AND METHODS

In the period from December 2014 to the current time 35 monopolar enucleations were performed in the clinic of urology Sechenov FMSMU. The mean age was 70,3+/-3,7 years; Prostate volume was 60,3+/-12,5 cm3; IPSS / Qol 24,6+/-3,3 / 5,1+/-1,1; Qsr 7.7+/-2.1 ml/s. We used resectoscope 26 Ch with constant irrigation, Hook-electrode, pusher-electrode, as well as a standard set of electrodes for mono- and bipolar surgery during the procedure. Enucleated adenomatous nodes were resected either by mono- or bipolar TURP and were laundered by Rene-Alexander syringe, or morcellated.

RESULTS

Comparative analysis of different methods of surgical treatment of prostatic hyperplasia (laser and monopolar enucleation) shows the advantages of monopolar enucleation in patients with prostatic hyperplasia.

CONCLUSION

Monopolar enucleation of prostate hyperplasia is a radical, as well as a safe and effective surgical method in the treatment of patients with BPH. Further observation of the operated patients will allow us to make a final conclusion about the place of this technique in the treatment of patients with BPH and adequacy of data.

[Holmium laser enucleation of the prostate (HOLEP) for small, large and giant prostatic hyperplasia. Practice guidelines. Experience of more than 450 surgeries]

INTRODUCTION

and objectives. Most of modern endoscopic procedures (e.g., TURP) are only confined to small and medium-sized glands (up to 80 cm3), but not HoLEP, which allows to enucleate large and extremely large prostates (200 cm3). The aim of the study was to compare the efficiency of HoLEP for prostates of different sizes.

METHOD

s. A total of 459 patients were divided into three groups: Group 1 included 278 patients (prostate volume <100 cm3); mean prostate volume, 70.8+/-16.1 cm3; IPSS, 18.7+/-5.5; QoL, 4.1+/-0.5; Qmax, 6.2+/-1.5 mL/s; post-voided residual volume, 64.2+/-30.5 mL. Group 2 included 169 patients (prostate volume 100-200 cm3); mean prostate volume, 148.1+/-25.2 cm3; IPSS, 19.7+/-3.3; QoL, 4.2+/-0.7; Qmax, 5.9+/-0.7 mL/s; post-voided residual volume, 70.9+/-20.1 mL. Group 3 included 12 patients (prostate volume >200 cm3); mean prostate volume, 230.1+/-18.1 cm3; IPSS, 19.5+/-4.5; QoL, 4.1+/-0.3; Qmax, 4.7+/-0.9 mL/s; post-voided residual volume, 72.3+/-10.9 mL. All the patients underwent HoLEP from 2013 to 2015. For the prostate to be enucleated, a 100-W laser system, 550-micron end-fire fiber, and a morcellator for tissue evacuation were used.

RESULTS

The average duration of surgery in Group 1 was 56.5+/-10.7 min; in group 2, 96.4+/-24.9 min; in Group 3, 120.9+/-35 min. The average duration of morcellation in Group 1 was 37.5+/-7.3 min; in Group 2, 63.3+/-11.2 min; in Group 3, 84.0+/-25.6 min. The efficiency of enucleation in Group 3 (1.70 g/min) was significantly higher (p < 0.05) than in Group 1 (1.05 g/min) and Group 2 (1.23 g/min). Similar results were obtained for the efficiency of morcellation. It was lower in Group 1 and Group 2 (1.58 and 1.87 g/min, respectively) than in Group 3 (2.45 g/min) (p<0.05). In order to compare the long-term results of HoLEP for prostates of different sizes, all the 459 patients were followed up for 18 months. IPSS, Qmax, QoL, and post-voided residual volumes were measured. There were no significant differences (p>0.05) in the postoperative outcomes for 1, 3, 6, 12, and 18 months after surgery.

CONCLUSIONS

It follows from our two years experience that HoLEP is a safe, highly efficacious and a size-independent procedure, which is why it has become a new gold standard for treatment of extremely large prostatic hyperplasia in our clinic.

[Radical prostatectomy in patients with incident prostate cancer]

The problem of detecting localized prostate cancer following transurethral resection of the prostate (TURP) for benign prostatic hyperplasia is fairly common. Historically, radical prostatectomy (RP) after previously performed TURP was associated with poor surgical and functional outcomes. It is believed that the periprostatic fibrosis, scar tissue and inflammation after previous TURP may interfere with the optimal RP results. The present retrospective study evaluates intraoperative characteristics, postoperative oncological and functional outcomes of RP in patients with a history of TURP.