[Risk factors for complications of ureterolithotripsy]

AIM

to determine main risk factors for complications of ureterolithotripsy.

MATERIALS AND METHODS

a retrospective analysis of the results of 545 ureteroscopies performed in 506 patients with ureteral stones over the past 7 years at the urological clinic named after M.F. Vladimirsky was carried out. The relationship between preoperative and intraoperative factors and complications of ureterolithotripsy was analyzed.

RESULTS

The overall complication rate was 22.4%. The risk of intraoperative complications was proved to increase (p<0.05) along with the stone size, location in proximal ureter, stone impaction for more than 3 weeks and the degree of hydronephrosis. No preoperative stenting or nephrostomy tube prior to ureteroscopy was associated to an increased risk of intraoperative complications (RR=2.88; p=0.03). Patients with preoperative drainage of upper urinary tract has lower probability of intraoperative complications (OR=0.35; p=0.03). The risk of developing stricture and ureteral obliteration in uncomplicated ureteroscopy was minimal (RR=0.008, p=0.0001). Small ureteral perforation and pronounced mucosal inflammation around the stone have the similar influence on the risk of complications, which was more than 7.5 times (p=0.0001) higher than in uncomplicated ureteroscopy. Large ureteral perforation was associated with the highest risk of stricture formation and ureteral obliteration, which was 64 times (p=0.0001) higher than in uncomplicated ureteroscopy.

CONCLUSION

The rate of complications of ureterolithotripsy directly depends on the following factors: size and location of the stone, the stone impaction, pre- and intraoperative (nephrostomy tube) drainage of the upper urinary tract, the degree of hydronephrosis, level of bacteriuria and intraoperative trauma complications.

[Validation of the Russian version of the ureteral stent symptoms questionnaire (USSQ) for the evaluation of quality of life and stent-related symptoms]

INTRODUCTION

Ureteral stents are frequently used in urology practice and have a significant impact on health-related quality of life (QoL). In 2003 . Joshi et al. developed the specific questionnaire for evaluation of QoL and stent-related symptoms, namely Ureteral Stent Symptoms Questionnaire (USSQ). USSQ consists of 40 questions and 2 visual analog scales (VAS), divided into 6 domains. Over the past decade, this questionnaire has been translated into 9 languages. A Russian version of the questionnaire has not been developed yet.

AIM

To perform linguistic validation of the Russian version of the USSQ.

MATERIAL AND METHODS

Linguistic validation of the original USSQ was performed through a standard process including translation, back translation and pilot study. A total of 103 patients undergone ureteral stent placement and successfully filled in the Russian USSQ at weeks 1 and 4 after stenting, and at week 4 after stent removal. In addition, 30 healthy people filled in the same questionnaires twice at 3-week intervals, as a control group. To evaluate reliability, validity and sensitivity to change of the Russian USSQ, statistical analysis was performed. External criteria included validated questionnaires (EQ-5D, IPSS and pain VAS).

RESULTS

Content validity was approved by experts and proved during patients interviewing. Reliability test-retest was satisfactory for urinary symptoms, body pain, general health, and work performance domains (p<0,001 between test and retest evaluation). USSQ domains showed good correlations between each other (correlation coefficient was 0,80-0,94). Cronbach's alpha coefficient of internal reliability was 0.73-0.95. Correlation between other instruments and corresponding USSQ domains was good (p<0,001), proving criterial validity. Sensitivity to changes after stenting and stent removal was also good for most domains (p less or equal 0,001).

CONCLUSION

Russian version of USSQ is a valid, reliable and sensitive instrument for the assessment of QoL and stent-related symptoms and is ready for application in the routine clinical practice.

[Bilateral acute purulent destructive pyelonephritis after retrograde ureteroscopy and lithotripsy]

The problem of urinary stone disease and acute destructive pyelonephritis remains to be relevant in the current urologic practice. The acute pyelonephritis is the most common infectious and inflammatory complication after retrograde ureteroscopy. According to data of leading urologists in Russian Federation and worldwide, the incidence of acute purulent pyelonephritis ranges from 0.1 to 0.2%. Infectious and inflammatory complications of retrograde ureteroscopy often require urgent interventions. Acute pyelonephritis can result in destructive changes in the renal parenchyma. In case of ineffective conservative measures, pyelonephritis can progress into sepsis with the development of multiple organ failure. Therefore, infectious and inflammatory complications require to start combined antibacterial, anti-inflammatory and detoxification therapy, as well as to resolve any upper urinary tract obstruction. If acute pyelonephritis leads to destructive phase with a formation of a carbuncle or an abscess in the kidney, an open surgery is indicated. Despite being minimally-invasive, retrograde ureteroscopy can lead to serious complications requiring an open surgical intervention. In some cases, the severity of the patients condition may require nephrectomy.

[Questions of terminology, systematization and grading of complications of contact ureteral lithotripsy]

AIM

To investigate the advantages and disadvantages of the current variants of systematization and grading of complications of contact ureteral lithotripsy (CULT) and develop a working classification of CULT complications.

MATERIALS AND METHODS

The study analyzed results of 545 fluoroscopy-guided endoscopic procedures performed at the MRRCI Clinic of Urology from 2008 to 2015 in 506 patients with ureterolithiasis.

RESULTS

The proposed and implemented classification and terminology of CULT complications unifies the diagnostic and management algorithm. This tool is more systematic and structured than the classical classification and universal methods of systematization and grading of CULT complications (classifying CULT complications in "major" and "minor", PULS scale, Satava and Clavien-Dindo grading systems). Given the lack of clear grading of ureteral rupture, it was divided into amputation (two-level rupture) and avulsion (one-level rupture). Using such term as extravasation of the contrast media and/or migration of the stone outside of the ureter is groundless because these complications occur only after the perforation of the ureteral wall. Therefore, these conditions are complications not of CULT, but of the ureteral wall perforation. The ureteral perforation was classified into macro- and micro-perforation.

CONCLUSION

The existing terminology, classification and grading of the CULT complications should undergo a more detailed analysis. None of the existing classifications of CULT complications afford them to be fully staged and systematized. The working classification of complications of CULT developed at the M.F. Vladimirsky MRRCI Clinic of Urology warrants a multi-center prospective study to validate it and investigate its effectiveness.

[FEATURES OF PERCUTANEOUS NEPHROLITHOTRIPSY IN PATIENTS WITH UROLITHIASIS OF SOLITARY KIDNEY]

The article describes the results of percutaneous nephrolithotomy (PCNL) in 49 urolithiasis patients with a solitary kidney. In 44 (89.8%) patients the calculi were located in the kidney, in 5 (10.2%) patients - in the upper third of the ureter. The calculi were single (18; 36.7%), multiple (14; 28.6%) or stag-horn (17; 34.7%). Efficiency of PCNL estimated immediately after surgery and at the end of the third month of observation was 75.5 and 93.9%, respectively. Stone size (p=0.594), the baseline state of urodynamics of the upper urinary tract (p=0.205) did not affect the renal clearance at PCNL. Enlargement of initial calculus size positively correlated with the number of required treatment sessions (p=0.013), duration of surgery (p<0.0001), and the length of postoperative hospital stay (p<0.0001). Complications were common (44.9%), but the auxiliary manipulations were performed infrequently (26.5%). No associations were found between the size of calculus, the number of complications and secondary manipulations (p=0.361). No correlations were found between the clinical form of a solitary kidneywith urolithiasis and the occurrence of complications during the treatment course (p=0.121), as well as between the presence of complications and the cause of the "loss" of the contralateral kidney (p> 0.05). Thus, percutaneous nephrolithotripsy is a highly effective method modality of treatment of solitary kidney urolithiasis. Appropriate selection of indications and contraindications for PCNL, preoperative preparation, surgical technique, postoperative patient management are of great importance.

[The choice of method of treatment of patients with stones in ureteropelvic junction]

Stones located in the UPJ are accompanied by the most severe violation of the upper urinary tract urodynamics compared to other localizations of stones, which often leads to severe septic complications requiring emergency care. The study has evaluated the results of treatment of 147 patients with UPJ stones using various methods of treatment, and their efficacy in these patients. Extracorporeal shockwave lithotripsy (ESWL) was performed in 55 patients, contact ureterolithotripsy (CULT)--in 23 patients, percutaneous nephroureterolithotripsy and nephroureterolithoextraction (PCNLT and PCNLE)--in 43 patients, and open surgery (ureterolithotomy, pelviolithotomy)--in 26 patients. The best results in all parameters were obtained from patients with stone size up to 1 cm after ESWL, as well as in patients with stone size greater than 1 cm after PCNLT (PCNLE). In these groups, full discharge of stone at 3 months after treatment was achieved in 95 and 97.7% of patients, respectively. Complications in the ESWL group were recorded in 14.6% of patients, in the PCNLT (PCNLE) group--in 9.2% of patients.

[Retrograde nephrolithotripsy in treatment of staghorn nephrolithiasis]

The article presents the results of 42 retrograde nephrolithotripsy (RNLT) performed on 38 patients with staghorn nephrolithiasis. The staghorn cacculi SN-2 were most frequently indication for the intervention. 3 months after surgery, full exemption of the kidney from the fragments was observed in 85,6% of patients. RNLT is an effective and safe treatment for patients with staghorn stones with relatively low need for additional procedures. RNLT allows to reduce postoperative hospital stay and recovery period of patients.

[Transcutaneous nephrolithotripsy in presenile and senile patients]

A total of 323 transcutaneous roentgenoendoscopic operations were made in 212 patients from January 2000 to December 2009 including 96 operations in 81 presenile and senile patients (87 and 9 operations, respectively). Transcutaneous nephrolithotripsy (TCNT) eliminated concrement from the kidney for one session in 59 (72.8%) patients. It proved to be the most sparing treatment in serious clinical situations and provided maximally complete evacuation of the concrement from the kidney. A total complication rate was 14.8%. All the complications were cured with conservative pharmacotherapy. TCNT has the same indications as open surgery, is a method of choice in presenile and senile patients with large, stag-horn and recurrent concrements of the kidney, impacted pelvicoureteral concrements, in impaired renal urodynamics and high bacteriuria. TCNT can be used as a second-line treatment in failure of extracorporeal shock-wave lithotripsy or in combination with it (sandwich-therapy) for complete concrement elimination.

[Choice of treatment in patients with urolithiasis of anomalous kidneys]

We studied efficacy of transcutaneous nephrolithotripsy (TNLT) in patients with urolithiasis and anomalous upper urinary tract. For two years we performed TNLT in 148 patients with complicated forms of urolithiasis and anomalous kidneys (age 18-86, 76 females and 72 males). The examination for urolithiasis has found different anomalies of the urinary tract in these patients: double pelvis and ureter (9 cases--6.1%), lumbar dystopy of the kideney (59 cases--39.9%), horseshoe kidney (12 cases--8.1%), solitary cyst of the kidney (43 cases--29.0%), parapelvic cysts (25 cases--16.9%). Extracorporeal shock-wave lithotripsy (ESWL) was conducted as first-line treatment in the other 139 patients with nephroliths under 1.5-2 cm in size who had the following anomalies of the urinary system: a solitary kidney (n=14), double pelvis and ureter (n=26), anomalous position of the kidney (n=46), anomalous shape of the kidney (n=20), simple and parapelvic cysts (n=33). A total of 154 TNLT were performed in 148 patients. Transcutaneous interventions were most frequent in the treatment of coral (31.3%) and pelvoureteral (14.6%) concrements, one-stage operation was made in 143 patients. Transcutaneous puncture nephrostomy as the first stage was made in 5 patients. The concrements were removed by one operative intervention in 132 (89.2%) out of 148 patients. Exacerbation of pyelonephritis as a postoperative complication was treated conservatively in 12.5% patients. Residual fragments were diagnosed in 16 patients. Of them, 11 patients had multiple and 5 patients had coral concrements. Residual fragments were removed in 14 patients either by renephroscopy or by ESWL. Treatment of 139 patients with concrements less than 1.5-3 cm in size consisted in 197 ESWL sessions. In combination of anomaly and urolithiasis the number of lithotripsy sessions per one patient was 1.8 +/- 0.2. The least number of ESWL sessions per one patient was conducted in patients with lumbar dystopy of the kidney (1.3 +/- 0.45), the greatest number in horseshoe kidney (3.8 +/- 0.8). Evacuation of the concrements after ESWL depended on the type of anomaly and concrement location. It was 61-69% in patients with anomaly of the shape and position of the kidney, in cystic anomalies is was 89-91%. Open surgery was indicated in 7 patients who needed plastic surgery of hydronephrosis (4) and obstructive megaureter (3). Thus, low-invasive operations provide high efficacy of urolith removal in patients with anomalies of the urinary tract and can replace traumatic open operations.

[Successful combined surgical treatment double giant ureterocele complicated by double ureterohydronephrosis, cascade lithiasis and uterine myomatosis]

A case is reported of a 58 year old patient with a diagnosis: double giant ureterocele, secondary multiple calculi of the right ureterocele, calculus of the inferior calyx of the right kidney, calculus of the terminal part of the left ureter, double ureterohydronephrosis, chronic pyelonephritis, multiple calcifying myoma of the uterus. A combined single-stage operation (panhysterectomy, deletion of multiple calculi of the right ureterocele, deletion of the calculus of the left ureterocele, crosscut right ureterectomy with excision of ureterocele, right ureterocystoneostomy by Leadbetter-Politano, installation of the double J-stent into the right kidney, crosscut and longitudinal left ureterectomy with excision of ureterocele, left ureterocystoneostomy by Leadbetter-Politano, installation of intubating drainage into the left ureter, cystostomy) followed by extracorporeal shock-wave lithotripsy were performed in this adult patient with combined pathology of the urinary system.

[Low-invasive techniques in the treatment of urolithiasis with application of innovative equipment made in Russia]

A total of 1100 sessions of extracorporeal shock wave lithotripsy (ESWL) were made in 720 patients with urolithiasis in the last decade with application of LGK-Compact lithotripter which generates shock waves electrodynamically and has no focusing lens. Such lithotriptor allows ESWL in patients with a high anesthesiological risk. Fitting the LGK-Compact lithotriptor with an endourological complex ENDO-MIT tooled for low-invasive interventions under X-ray control enabled treatment of 467 patients with urolithiasis aged 30-80 years. Most of the patients (66.04%) were at the productive age of 18-50 years. ESWL on the LGK-Compact lithotriptor was made in 182 patients (mean number of sessions was 2.1). Six and 12 month follow-up examinations registered complete elimination of the fragments in 169 patients. Thirty-four patients with concrements of the intramural ureter were exposed to 1 to 3 sessions. The fragments eliminated for 1-14 days after the session in 25 patients. Three patients developed stone path which evacuated spontaneously in two cases. For 3 years transcutaneous nephrolithotripsy was conducted in 214 patients. The concrements were removed during one operation in 156 (72.9%) patients, 58 (26.1%) patients had residual fragments. Reoperation was made in 34 patients 7-12 days after the first intervention. In the rest 24 cases (11.2%) residual fragments were removed by means of ESWL on LGK-Compact. Thus, ESWL is a leading technique in management of uncomplicated uroliths maximum 2 cm in size. When indications to ESWL are limited or this method is not effective, the role of roentgenoendoscopic interventions, such as transcutaneous nephrolithotripsy and transurethral contact ureterolithotripsy, takes on special significance. Such clinical innovation as endourological complex ENDO-MIT with lithotripter LGK-Compact made in Russia opens new perspectives of the treatment of urolithiasis and other urological diseases due to introduction of novel highly effective domestic technologies leading to a significant reduction in the number of postoperative complications and time of treatment, to 1.5-2 fold reduction in costs of equipment compared to foreign analogues.

[Current trends in the treatment of urological patients with transplanted kidney]

The examination and surgical treatment were performed in 34 kidney recipients (22 males and 12 females aged 16-65 years) with different urological diseases admitted to the urological clinic of M. F. Vladimirsky Moscow Region Research Clinical Institute in 1992-2007 3 weeks to 15 years after kidney transplantation. Most of the patients had urolithiasis, prostatic adenoma, some patients had renal cyst, implanted kidney tumor, tumor of the arteriosclerotic kidneys, posterior urethra stricture, posterior urethra valve. The recipients with such urological diseases as chronic pyelonephritis, vesicoureteral reflux, chronic prostatitis, chronic cystitis received conservative treatment outpatiently. Extracorporeal lithotripsy (ELT) was made in 12 patients (each patient, except one, was exposed to 2 sessions, one patient--3)--a total of 27 sessions. After the first ELT session fragments of the concrements (mean size 2-5 mm in diameter) evacuated spontaneously. Transurethral (retrograde) x-ray-endoscopic operations for removal of the transplanted kidney uroliths were not conducted as the newly created ostium in the upper part of the urinary bladder made it impossible to use a retrograde approach for elimination of the concrements. Kidney recipients with prostatic adenoma (2 and 5 years after transplantation) in 3 cases were subjected to scheduled TUR because of manifest obstructive symptoms. Four patients with AUR undergoing TUR showed intraoperative tissue hemorrhage as the operation was conducted during anticoagulant and anti-platelet therapy used early (3 months to 2 months after the transplantation. In view of this, TUR lasted longer as adequate hemostasis was needed. Urethral nitinol stenting was made in one patient with AUR and prostatic size over 60 cm3, TUR was made 4 months later. Thus, low invasive surgical interventions in kidney recipients with urological diseases have changed routive approaches to treatment of such patients consisting in open surgery which was often cancelled because of contraindications. ELT is a basic method of treatment of the transplant's uroliths, in other cases different endourologic interventions are used. Prostatic adenoma is treated, as a rule, surgically (TUR of the prostate).

[Prostamol-Uno treatment in patients with prostatic adenoma and chronic non-infectious prostatitis]

We studied efficacy and safety of prostamol-Uno (PU) monotherapy in patients with prostatic adenoma (PA) comorbid with chronic abacterial prostatitis (CAP) in a clinical open trial including 45-year-old males aged over 45 years with PA comorbid with CAP, having irritative and obstructive symptoms by IPSS above 8 points and duration 6 months or longer, by NIH-CPSI above 10 points and duration 3 months or longer. The patients had Qmax from 5 to 15 ml/s, urine volume 100-350 ml, residual urine volume under 150 ml, prostate size more than 25 cm3, PSA level under 4 ng/ml and no bacterial growth in the third urine portion seeding and/or prostatic secretion. The effect was assessed by the disease history, complaints, digital rectal examination of the prostate, the disease symptoms by IPSS, quality of life (QoL), NIH-CPSI, bacteriological tests of the urine and prostatic secretion, urinalysis, Nechiporenko test in 3 urine portions. Uroflowmetry, ultrasonic investigation of the urinary bladder and prostate, transrectal energy dopplerography of the prostate, PSA assay in the blood serum were made in all the patients. PU safety was evaluated by arterial pressure, heart rate, 6-lead ECG, total and biochemical blood count. Control examination 3 months after the treatment showed no negative changes. PU patients demonstrated reduction in IPSS index from 14 to 6.8 points and NIH-CPSI (from 18.4 to 12.3 points (from 13 to 11.2 and 17.1 to 16.8 points, respectively, in the controls). QoL reduced from 3.9 to 1.9, from 3.6 to 3.3 points, respectively. Qmax rose from 12.4 to 18.2 ml/s and 13.5 to 14.5 ml/s, respectively. PSA changed insignificantly. Side effects were mild. Spectral doppler examination detected improvement in prostatic blood flow after PU treatment in 16 (53.3%) patients. Resistance index as an index of peripheral vascular resistance increased from 0.48-0.54 to 0.7-0.72 (p < 0.05). Thus, PU effectively reduces irritative and obstructive symptoms typical for prostatic adenoma in combination with CAP.

[An open randomized comparative trial of efficacy and safety of selective alpha-adrenoblocker setegis (terazosin) in therapy of patients with chronic bacterial prostatitis]

An open randomized comparative trial of setegis (terazosine) has shown good subjective and objective results in patients with chronic bacterial prostatitis. The drug is well tolerated and produces insignificant side effects. It is also demonstrated that combined therapy with alpha-adrenoblockers is more effective that monotherapy with antibacterial drugs in patients with bacterial prostatitis.

[A case of complication of system scleroderma with AL-amyloidosis]

The article describes a case of systemic scleroderma complicated by a severe nephrotic syndrome after seven years in a 46-year-old patient. Rectal mucosal biopsy and right renal biopsy were performed to clarify the origin of the nephrotic syndrome and because amyloidosis was suspected. Massive amyloid deposits were found in biopsy material, colored with Congo red and studied in normal and polarized light. After processing with guanidine and coloring with Congo red, the material was studied in normal and polarized light; amyloid deposits preserved their congophilia and double refraction during two hours of incubation, which is typical of AL-amyloidosis. The patient was directed to a specialized nephrological department for the treatment of AL-amyloidosis.

[Vascular endothelial growth factor in patients with prostate cancer and benign prostatic hyperplasia]

The authors examined 25 patients with prostate cancer (PC) and 36 patients with benign prostatic hyperplasia (BPH). In the group of patients with morphologically verified PC mean serum level of vascular endothelial growth factor (VEGF) was significantly higher than in patients with BPH (p < 0.05). The study demonstrated strong negative association between VEGF and prostate specific antigen (PSA) levels (r = 0.72, p < 0.05) in PC patients. There was no association between VEGF serum level and the stage or malignancy of PC (Gleason score). In benign prostatic glands moderate VEGF expression was observed only in basal cells, whereas in cases of PC all tumor cells displayed active VEGF expression; the difference was significant (p < 0.05). High serum VEGF levels and its active expression in patients with PC suggest an important role of angiogenic factors in the pathogenesis of this disease. The negative association between VEGF and PSA serum levels in PC indirectly confirms antiangiogenic activity of PSA, shown before.

[Comparative analysis of open and endoscopic operative procedures outcomes for posterior urethra obliteration in males]

Endoscopic recanalization of posterior urethra (PU) obliteration (a novel method) was compared to open reconstructive-plastic operations. 242 patients with PU and vesicular cervix obliterations entered the study. 93 patients of group 1 have undergone open reconstructive-plastic operations, 149 patients of group 2 were operated endoscopically (endoscopic recanalization under transrectal ultrasonic control). Before surgery the patients were examined using standard tests, sonourethrography and intraoperative transurethral ultrasonic investigation were added. Recurrence rate in group 1 and 2 was 29.1 and 16.8%, respectively. The following complications were observed in group 1: acute pyelonephritis (22.5%), enuresis (14%), orchoepididymitis (9.7%), urinary fistulas (5.4%). The patients needed long-term postoperative immobilization (10-16 days, mean 14.8 +/- 1.1 days). After endoscopic recanalization under transrectal ultrasonic control, group 2 patients developed acute pyelonephritis (4.8%), orchoepididymitis (4%), orthostatic enuresis (4%), short-term urethral fever (85.9%). Bed regime in this group was necessary for 1-2 days (1.3 +/- 0.4 days). Mean postoperative hospital stay was 2.5-fold less in group 2. The conclusion is made that endoscopic recanalization under transrectal ultrasonic control has advantages over open reconstructive-plastic surgery: less frequent pyoinflammatory complications, enuresis, the absence of such complications as impotence, short penis, formation of urinary fistulas.

[Vascular endothelial growth factor and insulin-like-growth factors in prostate cancer. ]

To study the levels of vascular endothelium growth factor (VEGF), insulin-like growth factor of type I and II (IGF-I and IGF-II), prostate-specific antigen (PSA) and their correlations in prostatic cancer (PC) and benign prostatic hyperplasia (BPH), we examined 38 PC patients (mean age 66.6 +/- 5.5 years) and 80 BPH patients (mean age 60.3 +/- 2.5 years). Serum concentrations of VEGF, IGF-I and IGF-II were measured using kits made by R&D (USA), PSA by Boehringer Mannheim (Germany). Sensitivity and specificity of the tests were analysed by plotting the curves. The serum VEGF concentration in PC patients was 518.9 +/- 60.7 pkg/ml, in BPH patients--267.9 +/- 99.9 pkg/ml (p < 0.001). The IGF-I and IGF-II it was 178 +/- 19 and 136 +/- 9 ng/ml (p < 0.05), 400 +/- 31 and 351 +/- 23 ng/ml (p < 0.05), respectively. The ratio of growth factor concentration to PSA concentration in the blood serum in BPH patients was higher than in PC patients (p < 0.01). Sensitivity and specificity of PSA (4 ng/ml) made up 85.7 and 57%, VEGF (151.5 pg/ml)--76.2 and 57.6%, IGF-I (157 ng/ml)--57.6 and 50%; IGF-II (392 ng/ml)--57.5 and 50%, respectively. Sensitivity and specificity VEGF/PSA was 85.7 and 70%; IGF-I/PSA--84.2 and 75%; IGF-II/PSA--84.2 and 79.6%, respectively. Thus, the ratio of concentrations of IGF-I, IGF-II and VEGF to PSA level in blood serum has high sensitivity and specificity for PC detection. Clinical implications of serum levels of VEGF, IGF-I and IGF-II for prediction of PC course and detection is to be elicited.

[Use of ureteral stents in patients with kidney transplantation]

The aim of the study was to determine indications for application of ureteral stents for draining urinary tracts of the renal transplant, after low-invasive surgical interventions, for timing drainage, prevention and correction of complications. Ureteral stent insertion for management of urological complications after transplantation of the kidney was made in 36 patients (25 of them have ureteral stricture, 11 had ureteral necrosis). Low-invasive operations were made in 28 patients, open reconstructive plastic operations were conducted in 12 patients. According to 6-12 follow-up of the stented patients, recurrent ureteral stricture was detected only in 4 patients (11.1%). The stricture was corrected transcutaneously by antegrade ureteral stenting. It is concluded that stenting of the urinary tracts of the transplanted kidney in the treatment of urological complications--necrosis and ureteral stricture--in the course of low-invasive roentgenoendoscopic and open reconstructive-plastic operations raises treatment efficacy and prevents recurrent stricture.

[Extracorporeal shock-wave lithotripsy of bladder stones in patients with benign prostatic hyperplasia]

In urological department of Moscow Regional Research Clinical Institute, extracorporeal shock-wave lithotripsy (ECSWL) or bladder stones in patients with benign prostatic hyperplasia (BPH) has been made prior to TUR from 1991. This treatment was given to 52 patients aged 54-79 years with prostatic volume 40-120 cm3. Complete or partial fragmentation of the vesical calculi was achieved after 1 to 3 ECSWL sessions (a total of 105 sessions, 2000-3000 impulses a session). Pretreatment with ECSWL of bladder stones significantly facilitates TUR in BPH patients with vesical calculi of big size (2.5 cm and more in diameter). Extracorporeal fragmentation of large stones prior to TUR makes surgery of such patients less traumatic and reduces the risk of intraoperative complications compared to endoscopic cystolithotripsy or cystolithotomy. ECSWL of cystolithes expands indications for drug therapy or thermal non-endoscopic BPH treatment in aged patients with poor somatic status and in young sexually active males rejecting surgery.

[Telemetric shock-wave lithotripsy on a new Russia LGK-Kompakt 9701U lithotriptor]

During clinical tests of a new Russian [symbol: see text]K-Kom[symbol: see text]akt 9701[symbol: see text] lithotriptor, the Urological Unit of the Moscow Regional Research and Clinical Institute performed 73 sessions of telemetric shock-wave lithotripsy (TIWL) in 43 patients with urolithiasis (20 females and 23 males whose age ranged from 23 to 78 years). The tests indicated that the new device meets all present medical and engineering requirements for lithotriptors having an ultrasound stone-picking-up system and has some advantages over the analogues made in foreign countries in both medical and engineering indices. The device provides good images of renal calculi and destroys them effectively, of peripelvic and intramural portions of the ureter, and the urinary bladder. A positive effect of TIWL was achieved in 37 patients (calculous fragments moving away in full), minor calculous fragments remained in 6 patients (their treatment is under way). No complications associated with the action of shock waves generated by the [symbol: see text]K-Kom[symbol: see text]akt 9701[symbol: see text] lithotriptor on the kidney and adjacent organs were observed during the clinical tests. Post-TIWL control follow-ups (within the first 24 hours to 6 months after TIWL) revealed no noticeable structural changes in the renal parenchyma or worse renal function.

[Use of stent-nephrostomy in the treatment of renal transplant urologic complications by percutaneous surgical techniques]

Ureteral complications including stricture of the ureter and necrosis of the ureter with urinoma are the most frequent urological complications after renal transplantation. About 1-12% of recipients suffer from these complications. Percutaneous techniques allow correction of ureteral complications by less traumatic than open surgical operations and sufficiently effective method. Ureteral complications were registered in 20 cases (3.6%) out of 561 renal transplantations carried out in our institute from 1990 to 1995. Only in 5 cases open surgical correction was necessary, 15 patients after percutaneous nephrostomy underwent bougienage and/or balloon dilatation of ureter with further antegrade stenting. In all percutaneous operations special stent-nephrostoma developed in our department was used. Use of the stent-nephrostoma with its further transformation into the ureteral stent has some substantial advantages versus routine stent procedure.

[The treatment of obliterations of the posterior urethra in men]

The paper presents the analysis of treatment results for 345 patients with posterior urethra obliteration treated in 1981-1996. Of the various methods used, endoscopic operations proved most effective and safe. Two-stage recanalization of the posterior urethra is more sparing than plastic surgery as it does not employ traumatic approach, is shorter, is accompanied but less blood loss, makes postoperative complications less frequent. A novel treatment (endoscopic recanalization of the urethra under transrectal control) is much less traumatic, makes complications rare. Open plastic operations on the urethra should be made only in cases when obliteration of the posterior urethra is combined with urinary fistulas and when femur bones deformation induces urethral deviation.

[A comparative evaluation of the use of pyeloureterostomy and ureterocystostomy in treating the urological complications following kidney transplantation]

Ureteral stricture and necrosis after allotransplantation of the cadaver kidney were corrected in 14 and 7 patients, respectively. 12 patients have undergone ureterocystostomy, 9 patients--pyeloureterostomy with the recipient's ureter. Shortly after ureterocystostomy anastomosis insufficiency developed in 7 out of 12 patients, after pyeloureterostomy in 1 of 9 patients (p < 0.05). Secondary complications led to the transplants' rejection in 5 of 12 and 1 of 9 patients, respectively (p < 0.05). 2 patients died due to septic complications after ureterocystostomy. Long after surgery stricture in anastomosis and distal ureter occurred in 3 recipients after ureterocystostomy; after pyeloureterostomy (6 months and 2 years) nephrectomy was conducted in 2 cases because of clinical manifestations of pyelonephritis. It is inferred that pyeloureterostomy with the recipient's ureter is preferable to ureterocystostomy in the treatment of ureteral necrosis and stricture following transplantation of the kidney.

[Transurethral resection in patients with benign prostatic hyperplasia complicated by chronic calculous prostatitis]

Combination of benign prostatic hyperplasia (BPH) with chronic calculous prostatitis aggravates clinical symptoms of BPH and complicated its treatment. Pronounced dysuria, persistent pain are highly resistant to conventional chemotherapy. Prostatic stones promoted emergence of sclerotic and purulent complications impeding surgical treatment of BPH. Unsatisfactory results of transurethral resection (TUR) in BPH with chronic calculous prostatitis are attributed to impossibility to remove all the concrements. Visual control in TUR cannot localize the stones. Deep resection of the prostate at the site of expected stone location elevates the risk of enuresis and impairment of prostatic capsule. Surgical treatment of 16 patients has demonstrated that removal of all the concrements and prevention of the complications are possible under transrectal ultrasound control.

[The diagnosis and treatment of simple kidney cysts]

The authors have gained the experience of diagnosis and treatment of renal cysts in 182 patients. The disease was asymptomatic in 12 patients. The final diagnosis was established after ultrasound scanning in 98.35% of cases. At 3-92 month follow-up the recurrences arose in 26 (15.75%) from 165 patients subjected to transcutaneous puncture with administration of 96% alcohol for 10-15 min without draining. Another puncture was carried out in 9 (5.56%) patients. The recurrences were seen in all the 11 patients in whom aspiration was not followed by alcohol administration. 7 cases needed repeat puncture. The authors advocate transcutaneous puncture sclerotherapy with the use of 96% alcohol for treatment of symptomatic and large cysts of the kidneys.

[A familial form of nephrolithiasis in patients following kidney transplantation?]

Causes and mechanisms underlying nephrolithiasis after transplantation of the kidney differ much from known in other urological patients. We have found calculi in transplanted kidney in 5 of 939 surgical patients. Two cases of concrement formation in the transplant in the members of the same family aged 22 and 26 years we report as interesting. Our experience and literature data suggested family nature of the concrements. One of the patients underwent pyelolithotomy, the other impulse lithotripsy. Both the transplants function normally 5 years after kidney transplantation.

[The treatment procedure in patients with a combination of kidney tumor and urolithiasis]

Renal carcinoma and urolithiasis combine rather rarely. Postnephrectomy patients often consult the urologist when the condition is serious because of complications resultant from uroliths in the contralateral kedney. In view of solitary kidney, progressive chronic pyelonephritis, associated chronic renal failure surgical treatment of the condition becomes risky and necessitates individual approach to choice of therapeutic policy and definition of indications to urolithiasis treatment in patients after nephrectomy for renal carcinoma. This includes the decision whether to perform nephrolithiasis before or after nephrectomy and whether to attempt any surgery in the absence of urolithiasis clinical symptoms.

[Extracorporeal lithotripsy in the treatment of urolithiasis]

The material gained in the urological clinic of the Moscow Regional Research Clinical Institute covers 2000 cases of uroliths treated with extracorporeal lithotripsy (ECL) for 4 years. Factors implicated in the treatment outcomes, measures to prevent ECL complications, recommendations for ECL regimens in different clinical forms are specified.

[Urolithiasis in children]

The paper reviews the experience of the urological clinic in the treatment of 106 children with urolithiasis. The necessity of careful pretreatment examination to reject associated anomaly of the upper urinary tracts as a cause of lithogenesis is emphasized. Surgical treatment and extracorporeal lithotripsy which has proved highly effective against uroliths in children are considered.

[The ultrasonic diagnosis of vesicoureteral reflux]

Potentialities of ultrasonic investigation (USI) in diagnosis of vesicoureteral reflux (VUR) were elucidated by comparison of the USI evidence with that obtained at miction cystourethrography which had identified VUR of degree I-IV. Ultrasonic signs of active and passive VUR distinctly observable in the reflux degree III and IV are noted. The technique of USI in VUR-suspected children is described. Ultrasonic measurements of the intravesicular part of the lower ureter were made. It is shown that USI can serve a method of outpatient selection for miction cystourethrography. As demonstrated by the examination of 58 patients with transplanted kidney, USI is effective in identification of the reflux to the transplanted kidney as well as in differential diagnosis with obstructive complications after transplantation.

[The treatment of stones in the transplanted kidney]

The paper reports 3 cases of positive results achieved at extracorporeal lithotripsy for concrements in the transplanted kidney. To avoid such potential complications as subcapsular hematoma, rupture of the transplant, its ureter occlusion by the stone fragments, acute pyelonephritis, lithotripsy should be conducted in sparing regimen (low and moderate power, number of impulse per a session not more than 2000) under ultrasound control. In defective urine outflow from the transplant as a result of pretreatment obstruction by the stone or posttreatment obstruction by its fragments a drainage must be done by means of transcutaneous puncture nephrostomy.

[Current approach to solving the problem of urolithiasis]

The article analyses experience in the management of about 1,500 patients with urolithiasis who underwent in- and out-patient treatment at the Urological Clinic of the Moscow Regional Scientific Research Clinical Institute in 1990-1993. Indications were determined for applying lithotripsy in patients with stones in anomalous kidneys, in cases of a solitary kidney, and children with urolithiasis. The tactics of management of large kidney stones is described. The use of endoscopic methods of treatment (percutaneous and transurethral) is evaluated. Modern methods of urolithiasis treatment were applied instead of an open operation in 90% of patients.

[Comparative evaluation of two methods for the uretero-cystic anastomosis]

Comparative analysis of two types of ureterocystic anastomosis in kidney transplantation showed the advantages and shortcomings of the method developed at the Moscow Regional Scientific Research Clinical Institute. The new anastomosis fundamentally differs from the traditional Mebel-Shumakov method in the absence of sutures between the ureter and the bladder mucosa. This feature makes it possible to avoid injury to the bladder mucosa which is often changed in prolonged anuria and reduce the edema and ischemia of the terminal part of the ureteral graft. This facilitates adaptation of the anastomosis to polyuria which often occurs in the early postoperative period. The relatively simple techniques shortens the time needed for the operation. These advantages of the new method of ureterocystotomy are manifested by decrease of the total number of urological complications and the relative incidence of serious early urological complications like fistula of the ureterocystic anastomosis and necrosis of the ureter which most often lead to loss of the transplant and sometimes to death of the patient. The use of the anastomosis developed at the Clinical Institute, however, is attended by a relatively high incidence of ureteral stricture in the late-term postoperative period, evidently due to prolonged contact of urine with the bladder muscular coat and the ureteral adventitia. Thus, the more favorable results of ureterocystic anastomosis formed by the method developed at the Clinical Institute allow it to be recommended for further use in kidney transplantation.

[The treatment of ureteral stricture in patients following kidney transplantation]

Ureteral strictures in kidney recipients are serious urological complications often responsible for the transplant rejection and sometimes for the recipient's death. The stricture-related slight and nonspecific symptoms often underlie its late diagnosis and inadequate treatment. Obligatory follow-up ultrasonic investigations promote early detection of ureteral stenosis. Eight kidney recipients with ureteral stricture initially underwent transcutaneous puncture nephrostomy preserving the transplant function and preventing aggravation of the condition. In view of threatening infection and weak reparative capacity of immunosuppressed patients, less traumatic transcutaneous interventions seem preferable in further treatment: bouginage, balloon dilatation or the stricture dissection followed by insertion of the inner stent. In uneffective transcutaneous surgery due to extended ureteral strictures or complete obstruction of the ureter it is valid to conduct pyeloureterostomy with the recipient's own ureter.

[Extracorporeal lithotripsy in certain forms of urolithiasis]

Therapeutic results of remote lithotripsy have been analyzed for 1016 patients with urolithiasis. The authors also focus on specific features of remote lithotripsy in anomalous stones, in nephroliths on the single and transplanted kidney, in location of the stone in the ureter. The efficacy of the procedure is reviewed in pediatric patients. Satisfactory results were achieved in 962 patients (95%). Remote lithotripsy is considered to be a valuable component of combined treatment of urolithiasis replacing successfully open surgery in 95% of the cases.

[Ultrasonic study in the diagnosis of developmental defects and diseases of the urinary system in children]

Echography has recently become one of the leading methods of examination in different branches of medicine. Despite its high informativeness, however, it is not used widely in pediatrics. The article generalizes the practical experience accumulated in ultrasonic examination of urinary organs in children with developmental anomalies and diseases of the kidneys, ureters, urolithiasis, and Wilms' tumor. Besides, the possibility of echography as a screening test in outpatient examination of children with changed values of urinalysis is shown for the first time in pediatric practice. The authors describe the advantages of the method in combined developmental anomalies and regular medical examination of patients after various methods of treatment. They emphasize its merits (absolute safety, no injurious effect, high informativeness, the possibility of performing it in children who are in a grave condition, its extensive use under outpatient conditions, etc.). It is shown the ultrasonic examination in outpatient clinics makes it possible to divert from the traditional plan of radiourological examination of children, which includes excretory urography performed in children in inpatient clinics as a rule. It is obvious that the use of echography as a diagnostic test will make it possible to exclude the radiation load which is most harmful for the growing and developing organism and will not require mass hospitalization, which will undoubtedly have a high therapeutic and economical effect.

[Hyperthermia as a method for treating prostatic adenoma]

Local microwave hyperthermia was used in 15 patients aged 60 to 76 years with prostatic adenoma on an inpatient (n = 8) and outpatient (n = 7) basis. Severe clinical symptoms of prostatic adenoma was considered indication and urinary and prostatic stones were contraindications. Every patient received 6 hyperthermia treatments (41 to 42 degrees C) with a 915 or 460 MHz device. Adenoma of the prostate was treated twice a week. An interval of 3-4 days was used to avoid thermic tolerance. The treatments were well tolerated. Prostatic size was reduced by 15.2 cm2 in 11 patients and unchanged in 1 patient. Three patients required surgery 2 weeks after treatment withdrawal because of adenoma distension with residual urine and 3 patients were operated on for cystostomes. The overall effect of microwave hyperthermia on prostatic adenoma was induction of focal sclerosis in adenoma. This treatment improved uroflowmetric findings and abolished residual urine. Hyperthermia is a reasonably safe conservative option for inoperable patients with prostatic adenoma.

[Ultrasonic diagnosis of ureterocele]

Diagnostic ultrasonic investigation has found many applications in routine urologic practices. The use of ultrasound for the investigation of 19 patients with ureterocele is reported. High diagnostic value, simplicity and noninvasiveness of echographic diagnosis of this congenital malformation of distal ureteral portions and related complications are pointed out. Its advantages over conventional means of ureterocele diagnosis, such as excretory urography and cystoscopy, are demonstrated, while their shortcomings are avoided. Echography is particularly effective in cases of impaired renal activity, doubled upper urinary tract and segmentary ureterohydronephrosis. Ultrasound makes it possible to choose the type of surgical intervention, and exclude angiography from the diagnostic complex in some cases. Follow-up echographic examination after surgery for ureterocele provides adequate information on treatment results.