[Comparative study of the efficacy and safety of a new generation of thulium fiber lasers for ureteroscopy and lithotripsy]

INTRODUCTION

The development and implementation in clinical practice of a 3rd generation thulium fiber laser with the possibility of computer control (modulation) of the shape, amplitude and pulse repetition rate opens up new possibilities for thulium fiber laser lithotripsy.

AIM

To carry out a comparative study of the efficacy and safety of thulium fiber laser lithotripsy using a of the 2nd (FiberLase U3) and 3rd generation devices (FiberLase U-MAX).

MATERIALS AND METHODS

A total of 218 patients with solitary ureteral stones, who underwent to ureteroscopy with lithotripsy using 2nd and 3rd generation thulium fiber lasers (IRE-Polus, Russia) from January 2020 to May 2022 with the same peak power (500 W), laser settings of 1 joule, 10 Hz and with a laser fiber diameter of 365 m, were included in the prospective study. For lithotripsy using FiberLase U-MAX laser a new original modulated pulse, which was found and optimized in a preclinical study, was used. Depending on the laser, the patients were divided into 2 groups. In 111 patients, stone fragmentation was performed on FiberLase U3 (2nd generation), while 107 patients were undergone to lithotripsy on a new laser device FiberLase U-MAX (3rd generation). Stone size ranged from 6 mm to 28 mm (11+/-4 mm). The duration of procedure and lithotripsy, the quality of the endoscopic picture during fragmentation (from 0 to 3 points, 0-bad, 3-excellent), the frequency of retrograde migration of stones, as well as damage to ureteral mucosa (of 1-3 degrees) were evaluated.

RESULTS

The time of lithotripsy was significantly lower in the group 2 than in the group 1 (12.3+/-4.6 vs. 24.7+/-6.2 min; p<0.05). The average quality of the endoscopic picture was significantly better in the group 2 (2.5+/-0.4 vs. 1.8+/-0.2 points; p<0.05). Clinically significant retrograde migration of stone or its fragments (the need for additional ESWL, flexible ureteroscopy) was noted in 16% vs. 8% of patients in group 1 and 2, respectively (p<0.05). Damage to ureteral mucosa of the 1st and 2nd degree due to laser exposure in the group 1 was noted in 24 (22%) and 8 (7%) cases, compared to 21 (20%) and 7 (7%) cases in group 2, respectively. Stone-free state was 84% in group 1 and 92% in group 2.

CONCLUSION

Modulation of the laser pulse shape allowed to improve endoscopic visibility, increase the speed of lithotripsy, reduce the frequency of retrograde stone migration without increasing the trauma to ureteral mucosa.

[Experience in the use of confocal laser endomicroscopy for the diagnosis of bladder papillary tumors]

INTRODUCTION

Visual confirmation of suspicious changes in the urinary tract mucosa is the cornerstone in the diagnosis of urothelial cancer. However, with bladder tumors, it is impossible to obtain histopathological data during cystoscopy both in white light and in photodynamic and narrow-spectrum modes, as well as with computerized chromoendoscopy. Confocal laser endomicroscopy (probe-based confocal laser endomicroscopy - pCLE) is an optical imaging technique that provides high-resolution in vivo imaging and real-time evaluation of urothelial lesions.

AIM

To assess the diagnostic capabilities of pCLE in papillary bladder tumors and compare its results with standard pathomorphological study.

MATERIALS AND METHODS

A total of 38 patients (27 men, 11 women, aged 41-82 years) with primary bladder tumors diagnosed on the imaging methods were included in the study. For the diagnosis and treatment, all patients underwent transurethral resection (TUR) of the bladder. When a standard white light cystoscopy with assessment of the entire urothelium, 10% sodium fluorescein was administrated intravenously as a contrast dye. pCLE was performed with CystoFlexTMUHD 2.6 mm (7.8 Fr) probe, which was passed through the 26 Fr resectoscope using a telescope bridge to visualize normal and pathological urothelial lesions. A laser with a wavelength of 488 nm and a speed of 8 to 12 frames per second allowed to obtain an endomicroscopic image. These images were compared with standard histopathological analysis using hematoxylin-eosin (H&E) staining of tumor fragments removed during TUR of the bladder.

RESULTS

Based on real-time pCLE, 23 patients had a diagnosis of low-grade urothelial carcinoma, while in 12 patients the endomicroscopic picture corresponded to high-grade urothelial carcinoma, 2 patients had typical changes for inflammatory process and 1 case of carcinoma in situ was suspected, which was confirmed by histopathological study. Endomicroscopic images demonstrated clear differences between normal bladder mucosa and high- and low-grade tumors. In the normal urothelium, the larger umbrella cells are located most superficially, followed by smaller intermediate cells, as well as the lamina propria with blood vessels network. In contrast, low-grade urothelial carcinoma is characterized by denser, normal-shaped small cells located superficially than a central fibrovascular core. High-grade urothelial carcinoma exhibits markedly irregular cell architecture and cellular pleomorphism.

CONCLUSION

pCLE is a promising new method for in-vivo diagnosing of bladder cancer. Our results show its potential for endoscopic determination of the histological characteristics of bladder tumors and the ability to differentiate between benign and malignant processes, as well as the histological grade of tumor cells.

[Percutaneous nephrolithotomy in a patient after liver transplantation]

The work is devoted to the description of percutaneous nephrolithotomy in a patient who previously underwent liver transplantation. In case of immunodeficiency of any etiology, one-stage non-severe kidney injury is less dangerous compared to infectious and inflammatory complications, which naturally have more severe course compared to in those with intact immune system. Based on these considerations, the patient underwent percutaneous nephrolithotomy, which allowed to remove the stone of 2.5 cm in size without any complications. The choice of surgical treatment and management tactics for this category of patients are described in detail in the article.

[X-ray endoscopic treatment in patients with ureteral anastomotic obliteration after orthotopic neobladder formation]

INTRODUCTION

Strictures and obliterations of ureteral anastomosis after radical cystectomy with orthotopic neobladder reconstruction occur in 8-13% of cases, mainly in the first 2 years after surgery. According to the European Association of Urology guidelines, open reconstruction is considered the "gold standard" for the treatment of those patients. At the same time, according to various publications, X-ray endoscopic treatment of ureteral anastomotic strictures can be performed, especially in patients who have undergone orthotopic neobladder reconstruction.

MATERIALS AND METHODS

Three clinical cases of endoscopic treatment of ureteral anastomotic obliteration after orthotopic neobladder formation are presented. In all patients, nephrostomy tube was initially put due to acute pyelonephritis. Obliteration of the ureteral anastomosis was diagnosed by contrast-enhanced multispiral computed tomography and antegrade pyelography. The length of obliteration in all patients did not exceed 1.0 cm. The recurrence of the bladder cancer was excluded. After percutaneous opacification of the pelvicalyceal system and advancement of two guidewires ("working" and "safety") to the level of ureteral obliteration, a catheter with a built-in fiber optic light source was put in antegrade fashion along the "working" guidewire to the area of obliteration. During transurethral inspection of the reservoir, the distal end of the light source was visualized and the reservoir wall was cut "to the light" using electrosurgery (n=2) and a thulium fiber laser (one case). For adequate kidney drainage, two internal stents of 6 Fr were put for a period of 6 months in two patients and for 2 months in another case.

RESULTS

All patients had an adequate diameter of the ureteral anastomosis after removal of the stents. In two cases, an adequate passage of the contrast agent through both ureters was maintained for 42 and 37 months after procedure (according to the follow-up computed tomography and excretory urography). One patient had an attack of acute pyelonephritis 2 months after the removal of internal stents due to recurrent stricture. After repeated endoscopic ureteral recanalization with putting of two internal stents for a period of 6 months, no recurrence of the stricture was observed during 28 months of follow-up.

CONCLUSION

Endoscopic treatment of both primary and recurrent short ureteral anastomotic obliterations in patients with orthotopic neobladder allows for adequate ureteral patency, provided that two internal stents are left in place for 6 months.

[Endoscopic marsupialization of parapelvic renal cysts]

INTRODUCTION

Parapelvic renal cysts are very common. Indications for surgical treatment are upper urine tract obstruction, pain and recurrent gross hematuria.

AIM

To analyze the efficiency and safety of endoscopic transurethral and percutaneous laser marsupialization of parapelvic renal cysts.

MATERIALS AND METHODS

A total of 9 patients were undergone to transurethral intrarenal marsupialization of parapelvic renal cysts from March 2016 to February 2021 (4 men, 5 women, aged 42-78 years). Another 2 patients (2 men, aged 46 and 52 years) were treated by percutaneous approach. The average size of the cyst according to contrast-enhanced multi-slice computed tomography (MSCT) was 3.1+/-1.8 cm. In two cases, papillary tumor of the pelvis was suspected. The anteroposterior diameter of the pelvis was 2.6+/-1.3 cm; 9 patients had pain in the loin area, while in 7 patients recurrent gross hematuria was also an indication for surgical treatment. For marsupialization, a holmium (Ho:YAG) laser Auriga XL (Boston Scientific, USA) was used in 4 patients, and in other cases (n=7) a procedure was performed using a thulium fiber laser (Tm Fiber) Fiberlase U1 (IRE-Polus, Russia). In 3 patients, to clarify the site of incision of the cyst, intraoperative ultrasound was used. In all cases, after draining the cyst, an internal stent was placed inside the cyst for a period of 4-6 weeks.

RESULTS

The duration of transurethral surgery was 26+/-11 minutes, while percutaneous marsupialization of the cyst, which was performed in combination with percutaneous nephrolithotomy, took 10 and 18 minutes, respectively. The average catheterization time was 12+/-8 hours. Nephrostomy tube was removed on the 2nd day. The length of stay was 4+/-2 days. Febrile fever was noted in 1 patient (9%), which required a change in antibiotic therapy. During ultrasound control at discharge, the dilatation of the collecting system was not detected in any cases, while the residual cavity was found in 2 patients (18%). Follow-up contrast-enhanced MSCT and ultrasound within 3-30 months in all patients (n=11) showed no dilatation of the collecting system. In 1 (9%) patient, the residual cavity was preserved with a decrease in size to 1.2 cm without signs of upper urinary tract obstruction; the initial diameter of the cyst in this patient was 4.9 cm. There was no recurrence of gross hematuria.

CONCLUSIONS

In our opinion, transurethral and percutaneous laser marsupialization of parapelvic renal cysts is an effective and safe method that allows definitive treatment for cysts up to 4 cm in size. If the cyst is larger than 4 cm, endoscopic removal should be balanced with the possibility of preserving the residual cavity. The most common complication of endoscopic treatment of intrarenal cysts is acute pyelonephritis with a rate of 9%.

[Long-term results of combined treatment of patient with multiple primary cancers, including locally-advanced renal cell cancer, bladder cancer and transitional-cell cancer of the contralateral kidney]

A clinical case of the successful surgical treatment of patient with multiple primary cancers, including locally-advanced right renal cell cancer, transitional-cell cancer bladder cancer and metachronous transitional-cell cancer of the left kidney with one of the longest follow-up and survival time described in the literature.

[Transurethral endopyelotomy using thulium fiber laser]

INTRODUCTION

Transurethral endopyelotomy is an alternative treatment method for short stricture of ureteropelvic junction (UPJ).

AIM

to evaluate the efficiency of transurethral thulium laser endopyelotomy.

MATERIALS AND METHODS

A total of 94 patients with UPJ obstruction during the period from December 2016 to December 2018 were prospectively enrolled in the study. Pelvic size did not exceed 3 cm in 31 patients, and it was in the range from 3 to 4 cm and more than 4 cm in 35 and 28 cases, respectively. Depending on the treatment, all patients were divided into 2 groups. The main group included 48 patients who underwent retrograde thulium fiber laser endopyelotomy. In the control group (n = 46), patients underwent Anderson-Hynes laparoscopic pyeloplasty. In the main group, there were significantly more patients with more preserved ipsilateral kidney function, with short (less than 1 cm) and recurrent UPJ strictures and less severe hydronephrosis compared to the control group. In addition, there were no patients with crossing vessel in the main group. Postoperatively, an internal stent of 6-8 Fr was put in all patients for a period of 6-8 weeks. After stent removal, all patients underwent a follow-up examination, including an ultrasound examination and, if pelvic size was more than 3 cm, contrast-enhanced CT-urography was performed.

RESULTS

In all patients, after stent removal, a decrease in the pelvic size was noted. The operation time in the main and control group was 24+/-14 minutes and 82+/-26 minutes, respectively. In all cases, ureteropyeloscopy was performed prior to laparoscopy to determine the exact length of stricture and to exclude narrowing of other parts of the ureter. After follow-up of 24 months, an examination in 36 patients of the main group and 29 patients of the control group was performed. There was 1 recurrence after laparoscopic pyeloplasty and 1 recurrence after endopyelotomy. In other patients of both groups, there were neither stricture, nor impaired renal function.

CONCLUSION

The first experience of using a thulium fiber laser for transurethral endoscopic treatment of UPJ obstruction is presented in the article. Indications for the transurethral thulium endopyelotomy are the presence of primary or secondary UPJ obstruction (with a decrease in kidney function by no more than 40%), length of up to 1 cm, absence of an additional vessel and pelvic dilatation of no more than 4 cm.

[Bipolar and laser endoscopic enucleation for large benign prostatic hyperplasia]

BACKGROUND

endoscopic enucleation is a conventional minimally invasive method of surgical treatment for large prostates.

AIM

The aim of the study was to analyze preoperative, intraoperative, immediate postoperative outcomes and 12-month functional results of endoscopic enucleation of the prostate.

MATERIALS AND METHODS

a total of 120 endoscopic enucleations were performed in the Department of Urology, City Clinical Hospital named after D.D. Pletnev in 2016-2017. Bipolar electroenucleation was performed in 63 cases, while laser enucleation was done in 57 patients (28 holmium and 29 thulium). Three-lobe, two-lobe and en-block electroenucleation was performed in 23, 24 and 16 patients, respectively. The technical advantages of laser enucleation included lesser need for mechanical traction during enucleation of the adenoma from the prostatic capsule and the predominant use of two-lobe technique (33 cases). En-block laser enucleation was done in 7 patients, while three-lobe technique was used in 17 patients. Both groups were comparable in terms of I-PSS, QoL, prostate volume, maximum urination rate, and residual urine volume.

RESULTS

weight of the removed adenoma after electroenucleation was 105+/-24 g and 98+/-18 g after laser enucleation; the operation time was 118+/-10 and 132+/-25 min, duration of the catheterization 48+/-16 and 51+/-10 h, length of stay 3.6+/-1.2 and 3.8+/-1.3 days, respectively. Closed prostate perforation more often occurred after electrosurgical enucleation (6 vs. 1). There were no significant differences in the outcomes in both groups one year after the surgery. After removal of the urethral catheter, incontinence developed in 9% (6/63 and 5/57, respectively) of cases. During the period from 6 to 12 months, urinary incontinence persisted only in one patient, who subsequently was underwent to injection therapy with a partially positive effect. All 22 patients with urinary disturbances that occurred after enucleation had a short distance from the top of the verumontanum to the external sphincter (less than 1.5 cm; risk ratio (RR) = 3.5) and intravesical protrusion of more than 1 cm (RR=2.1).

CONCLUSION

endoscopic bipolar and laser enucleation is an effective and safe treatment method for large BPH. It should be noted that postoperatively there was an increased frequency of irritative symptoms, which disappeared by 6 months.

[Lower urinary tract symptoms after transurethral resection of the prostate]

An analysis of the frequency of residual lower urinary tract symptoms after surgical treatment is presented in this literature review. A special attention is paid to prognostic criteria for persistence of irritative symptoms after the surgery. The analysis of modern approaches to the treatment of urinary disturbances has been performed. The possibility of the combined use of various classes of drugs to improve the efficiency of the treatment is highlighted.

[Micropercutaneous laser nephrolithotripsy]

INTRODUCTION

The least invasive technique of PCNL is micropercutaneous nephrolithotripsy (micro-PCNL). A possibility of kidney puncture under direct endoscopic control with the creation of a working channel sized of 8-4.85 F is a characteristic feature of this system.

AIM

To study the possibilities of micro-PCNL and to determine its role in the treatment of kidney stones.

MATERIALS AND METHODS

A total of 74 patients aged 49.8+/-16.3 years were included in the study. In majority cases an isolated kidney stone was diagnosed (86.4%). The most common stone localization was pelvis (51.5%), followed by lower pole (35.9%). Considering the technical aspects of microPCNL, all patients were divided into 2 groups depending on the stone burden. In 46 patients (62.1%), the stone size was < 1.5 cm, while in 28 patients (37.9%) stones were bigger than 1.5 cm. Prestenting was performed in 54.0% due to renal colic or obstructive pyelonephritis. For the purpose of passive flushing of stone fragments during the lithotripsy, in most patients with a stone size > 1.5 cm, as well as in some prestented patients a ureteral access sheath with a diameter of 10/12 F (56.7%) was placed under x-ray control. In most patients with stones less than 1.5 cm, a 4.85 Ch sheath was utilized. In patients with larger stones, working sheath of 8 Ch was put. For stone disintegration, 50 W and 100 W holmium lasers, as well as the Russian innovative thulium fiber laser were used.

RESULTS

The average duration of surgery from the puncture was 30.6+/-11.6 minutes. The effectiveness was determined by use of a non-contrast computed tomography, performed one month after the surgery. An overall stone-free rate after one-session was 89.1%, and it was 93.4% and 82.4%, respectively, in patients with stones sized less and more than 1.5 cm. In 32.4% cases the stenting was placed due to the large number of small residual fragments and risk of obstruction. In one case, a conversion into a mini-PCNL was done. Two patients (2.7%) required stenting because of renal colic caused by the migration of stone fragments into the ureter. There was no bleeding. In 8.1% of cases, acute pyelonephritis was developed that was treated conservatively. In 9.4% of patients, ESWL was required due to residual stones diagnosed one month after the surgery.

CONCLUSION

Micro-PCNL is highly effective and safe method for treatment of kidney stones. Placing of ureteral access sheath of size 10/12 F contributes to the passive flushing of fragments during lithotripsy, which, together with the use of the 8 F working sheath, makes it possible to effectively perform micro-PCNL in patients with kidney stones larger than 1.5 cm.

[Percutaneous nephrolithotripsy in a patient with primary immunodeficiency (a case report)]

This article presents a case study of a female patient with primary immunodeficiency, who underwent percutaneous nephrolithotripsy. The presence of a serious concomitant disease affects different aspects of preoperative and postoperative management of the patient. The choice of percutaneous nephrolithotripsy is necessitated by the need to render the patient stone free using a one-stage and the most effective surgical modality. The article describes the choice of antibacterial therapy to treat inflammatory complications in this category of patients. Broad-spectrum antibiotics should be used to prevent the onset of pyelonephritis, while pyelonephritis exacerbation requires administration of reserve antibiotics in combination with human immunoglobulin.

[Initial experience in clinical application of thulium laser contact lithotripsy for transurethral treatment of urolithiasis]

INTRODUCTION

The choice of an effective and safe method of disintegration of stones in upper and lower urinary tract is very important in the context of continuous scientific and technological progress. In current clinical urological practice, various lithotriptors with rigid and flexible probes are used for contact disintegration of stones, having both advantages and disadvantages. This study aimed to analyze the first results of the clinical application of the native Tm: fiber Urolaz laser (STA IRE-Polyus, Russia) for contact transurethral lithotripsy.

MATERIALS AND METHODS

The study comprised 56 patients who underwent transurethral contact thulium laser lithotripsy for 68 stones of the upper and lower urinary tracts between April and September 2017. Forty-four patients had kidney and ureteral stones, and twelve patients had urinary bladder stones. Twenty-four kidney stones were removed by retrograde intrarenal surgery using ureteral casing, flexible ureteropyeloscope and thulium laser, 32 stones in various ureteral segments - by rigid contact thulium laser ureterolithotripsy and 12 bladder stones - by thulium laser cystolithotripsy. The size of the upper urinary tract stones varied from 0.6 to 1.8 cm, bladder stones measured from 1.1 to 3.5 cm. Also, experimental studies were carried out to investigate the effects of the fiber thulium and holmium laser on the stone displacement and temperature environment during lithotripsy.

RESULTS

Full stone fragmentation was achieved in 100% of patients. 47.7% of patients required additional lithoextraction of fragments; there was no retrograde migration of large stones. The mean duration of stone disintegration was 19 minutes. Postoperatively, 15.9% of patients had an exacerbation of pyelonephritis, which was successfully managed by conservative measures. The mean postoperative hospital stay was 2.4+/-1.1 days. At follow-up examination 4-6 weeks after surgery, one patient was found to have a residual symptomatic ureteral stone, which required extracorporeal short-wave lithotripsy. The experimental study showed that fiber thulium laser lithotripsy produced much less propulsion of artificial stone than Holmium laser lithotripsy. With the use of therapeutic power, neither of the lasers resulted in "dangerous" rises of the washing fluid temperature during stone disintegration.

CONCLUSION

Using the universal thulium laser system "Urolaz" provides a significant improvement in the effectiveness of endourologic upper urinary tract interventions and significantly reduces the likelihood of intraoperative trauma and postoperative complications, which contributes to improving the quality of specialized urological care.

[Solitary stones of the lower renal calyx: how to treat?]

INTRODUCTION

The choice of treatment for the stones of the lower renal calyx is one of the challenging issues of modern urology. The aim of this retrospective and prospective study was to investigate the clinical effectiveness and safety of 3 modern minimally invasive techniques for treating renal stones: percutaneous (PNL) and transurethral (TNL) nephrolithotripsy and extracorporeal shock wave lithotripsy (ESWL) in patients with solitary lower calyx stones sized from 10 to 15 mm.

MATERIALS AND METHODS

The study included 136 patients with symptomatic stones of the lower calyces, who underwent ESWL, PNL and TNL from November 2010 to the present day. The criteria for inclusion in the study were: the presence of a solitary stone of the lower calyx, the stone size of 10 mm to 15 mm, the performance of the classical (standard) PNL in the prone position (puncture access 28-30 Fr) and the follow-up examination at 3 months after the operation. Forty-six patients underwent ESWL, 49 - PNL, and 41 - TNL. Postoperative follow-up was done at 3 months and included a plain radiography, ultrasound and non-contrast-enhanced computed tomography. The stone free rate (SFR) was used as a criterion for the effectiveness of the intervention, where the stone size of 3 mm was taken as the upper limit for the possible presence of fragments. Besides, the rate of repeat interventions, complications and subjective assessment of patients treatment satisfaction (0 to 10) by using visual analogue scale (VAS) were investigated.

RESULTS

The effectiveness analysis of the three methods for treating the lower calyx stones sized 10-15 mm showed that PNL was no more effective than TNL (SFR 95.9% and 85.4%, respectively), but both methods were significantly more effective than ESWL (SFR 69.5%). 29.3% of patients who underwent TNL required repeat interventions (TNL or ESWL), while among those treated with ESWL, 45.6% required repeat ESWL sessions. PNL resulted in stone clearance in one stage. Postoperative inflammatory complications were most prevalent among patients who underwent TNL (26.8%). Bleeding requiring hemotransfusion was observed only after PNL (14.3%). Obstructive complications were observed in all study groups. For them, internal stenting was most often performed after ESWL (10.9%), puncture nephrostomy - after TNL (7.3%). Statistically significantly higher VAS measured quality of life was found after ESWL (7.9) and PNL (7.0) compared with THL (4.8).

CONCLUSION

All three methods (PNL, TNL and ESWL) for treating lower calyceal stones sized from 10 to 15 mm are quite effective. Using them separately or in combination allows most patients to safely achieve a stone-free state.

[Ultraminipercutaneous nephrolithotripsy in treating kidney stones]

INTRODUCTION

Percutaneous nephrolithotripsy (PNL) is the recommended method of surgical treatment of kidney stones of size greater than 2 cm. Trends in the development of modern urology have been steadily toward less traumatic method to treat nephrolithiasis - minimally invasive PNL. The present work aimed to explore of the possibilities of one of the modern variants of minimally invasive PNL - ultra-mini-PNL in treating nephrolithiasis.

MATERIALS AND METHODS

The study included 60 patients (mean age 45.6+/-7.2 years) with isolated kidney calculus, up to 2.0 cm or several stones with a total size of up to 2.5 cm. All patients were found to have 77 kidney stones, six of which had a size of 10 mm, 51 had a size of 11-15 mm and 20 had a size of 16-20 mm. 45% of patients had isolated renal pelvic stones and 28.3% had stones in the renal pelvis and lower calyx. All patients underwent ultra-mini-PNL using nephroscope size 7.5 Ch and tube size 12 Fr.

RESULTS

The average duration of surgery from the moment of the puncture of the pyelocaliceal system to installing the nephrostomy tube was 65.4 minutes. Complete clearance of stones after single-stage ultra-mini-PNL was observed in 80% of cases. Nephrostomy tube was removed on days 2-3. The average postoperative hospital stay was 5.1 days. The most common complication was postoperative exacerbation of pyelonephritis (13.3% of patients), successfully treated with conservative measures. There were no cases of postoperative bleeding, accompanied by anemia and needed a blood transfusion.

CONCLUSION

Considering high effectiveness and low rate of complications of ultra-mini-PNL, it can be successfully used in treating nephrolithiasis among a wide group of patients.

[NARROWED SPECTRUM DIAGNOSTICS AND COMPUTER CHROMOENDOSCOPY IN THE DIAGNOSIS OF EPITHELIAL NEOPLASMS OF THE LOWER AND UPPER URINARY TRACT]

Tumors of epithelial origin occupy the first place in the structure of oncological diseases. This study was aimed to the evaluation of the possibilities of narrowed spectrum endoscopy and computer chromoendoscopy in the diagnosis of epithelial structures of the bladder and upper urinary tract.

MATERIALS AND METHODS

Additional diagnostic endoscopic examination of the lower urinary tract was performed in 76 patients (132 urethrocystoscopies). For the evaluation of the efficacy of complementary technologies in the endoscopic examination of the upper urinary tract, 47 patients were examined (57 endoscopic examinations of UUT).

RESULTS

During endoscopic examination of the bladder only in the "white light", 80 suspicious lesions were identified and removed. The additional use of NBI--diagnosis allowed to reveale and remove 9 (9.5%), abnormal structures, 6 of them (66.7%) were representatives of transitional cell carcinoma. The additional use of a computer chromoendoscopy revealed 6 (6.3%) neoplasms missed during endoscopy in white light: 4 samples (66.7%) were transitional cell carcinoma, 1 (16.7%)--squamous papilloma. Endoscopic examination of the upper urinary tract only in the "white light" identified and removed 47 suspicious lesions. Additional application of narrowed spectrum regimenhas allowed to identify and remove 8 (12.9%) pathological lesions, 3 (37.5%) of which were morphologically transitional cell carcinoma. The additional use of a computer chromoendoscopy indentified 7 (11.3%) tumors missed during endoscopy of UUT in "white light", 4 (57.1%) of which were transitional cell carcinoma. All other biopsies obtained were representatives of chronic inflammation, or material was not suitable for morphological examination.

CONCLUSIONS

Our experience of the use of narrowed spectrum diagnostics and computer chromoendoscopy allowed to improve the diagnosis of bladder cancer by 14.3%, and to improve the detection of transitional cell carcinoma of the upper urinary tract by 14.9% at the stage of development of the method.

[NEW OPTIONS OF ENDOSCOPIC TREATMENT FOR KIDNEY AND URETER STONES IN OBESE PATIENTS]

Effective urolithiasis treatment, especially in overweight patients has a considerable medical and social implication. Extracorporeal shock wave lithotripsy (ESWL) and percutaneous nephrolithotripsy (PCNL) in prone position of the patient are standard treatment options for kidney and ureter stones. These interventions are not always effective in patients with concomitant obesity and are associated with technical difficulties and an increased risk of complications. The study included 175 patients with obesity. The first group consisted of 96 (54.8%) patients treated with transurethral contact lithotripsy. The 2nd group consisted of 54 (30.9%) patients who underwent PCNL in the supine position. The third group comprised 25 (14.3%) patients with multiple stones of kidney and ureter, who underwent combined transurethral and percutaneous intervention in the supine position. The 1st and 3rd group had a higher prevalence of patients with II degree of obesity, in the 2nd group--with I degree of obesity. The mean duration of surgery in 1st group was 43.4 min, in the 2nd--70.3 min and in the third--84.6 min. Method of kidney drainage depended mainly on the presence, location and size of residual stone fragments. The average duration of the kidney drainage stent in patients of the 1st group was 39 days (ureteral catheter--1.3 days). In all patients of the 2nd and 3rd groups, at the final stage of the operation a nephrostomy tube was placed for an average of 2.7 days. The average postoperative hospital stay was 2.9 days in the 1st group, 4.1 days in the 2nd group and 4.5 days in the third group. In the 1st group, the stone-free status was achieved in 81 (84.4%) patients. Another 10 (10.4%) patients later needed ESWL for the complete disposal of the stones. In the 2nd group, the complete clearance of kidney stones was achieved in 49 (90.7%) patients. Another 3 (5.6%) patients required added ESWL to achieve the stone-free status. In the third group of patients stone free status was reached in 22 (88%) cases. In the remaining patients residual stone fragments were not clinically important. The most prevalent postoperative complication in all groups was postoperative pyelonephritis. Taking into account high efficiency of transurethral lithotripsy and PCNL in the supine position, as well as their combinations we can recommend these interventions to treat patients with kidney and ureteral stones and concomitant obesity.

[Transurethral electroenucleation of benign prostatic hyperplasia]

Currently, the choice of treatment of benign prostatic hyperplasia (BPH) remains one of the most pressing issues of Urology. The study explored the potentials of monopolar electroenucleation of BPH using a monopolar electrode-pusher and standard equipment for transurethral resection. From January to May 2013, 38 patients with infravesical obstruction caused by large BPH underwent transurethral monopolar electroenucleation. The control group (n = 44) consisted of patients who underwent the traditional monopolar transurethral resection of the prostate of the same size. All patients underwent an identical complex of clinical laboratory tests in the preoperative period and 1, 6 and 12 months after surgery. The technical features of the new technique are presented, intraoperative complications are assessed, early and late results and complications are evaluated. It has been established that one of the significant advantages of this method is the ability to remove significant amounts of adenomatous tissue with low risk of bleeding complications.

[Comparative evaluation of efficacy of electropulse and laser lithotriptors in vitro]

The article presents a comparative study of the nanosecond electropulse and holmium laser lithotriptors in vitro. Two types of samples simulating the "hard" and "soft" urinary stones were used; for their preparation stomatological ultrastrength plaster BegoStone was used. For the tests, four sizes of samples of stones in the cuboid shape were made. The sizes of the probes and stones, to some extent, simulated real clinical situation. In the experiments for Ho:YAG laser lithotriptor (LL), three sizes of probes were used: 230, 365 and 600 microns; for electropulse lithotriptor (EPL) - 2.7, 3.6, 4.5, and 6 Fr probes. A comparison of the effectiveness of lithotriptors in the experiments was performed for pairs of probes, which corresponded to a specific size of the stones. Comparative studies were performed in water at room temperature. "Stones" with specified size for each type of probe of lithotriptors were placed on stainless steel mesh with a mesh size 2 x 2 mm, immersed in water. Distal part of the probe (tip) was placed at an angle of 900 to the horizontal surface of the "stone" and brought into contact with the sample. The experiment was stopped when the surface of the mesh was free of particles of "stone" destroyed. Each experiment with the type and size of the "stone" and the probe was repeated at least 5 times. The results showed that nanosecond EPL requires much lower energy and time costs than the LL, ie, its physical parameters are more effective for the destruction of all types of samples stones. For the destruction of the "soft" stones, EPL always required much less energy than for the he destruction of "hard" stones. At the same time, working with LL often required same energy, and sometimes even more than for the destruction of "hard" stone. For the two methods of contact lithotripsy, different depending on the pulse energy and the properties of the "stones" in their destruction is confirmed experimentally.

[Pilot experience of percutaneous nephrolithotripsy in dorsal positioning of the patient]

Percutaneous nephrolithotripsy (PNLT) is widely used in surgical treatment of nephrolithiasis. The patient's body position in this operation is, as a rule, prone. However, this position is often uncomfortable or even impossible for patients with obesity, bone diseases and deformations which sometimes occur in pulmonary, cardiovascular and other diseases. The aim of our study was to see how dorsal positioning of the patient during PNLT influences the results of this surgery. A total of 109 patients after PNLT for concrements of the upper urinary tract entered the study. They were divided into two groups: operated in the dorsal position (n = 46, 42.2% - the study group) and operated in the standard prone position (n = 63, 57.8%--the control group). The patients were matched by gender, age, size and location of the concrements, surgical procedure. Residual concrements were detected in 9(19.5%) patients of the study group, 7 of them were reoperated (PNLT, ureterolithotripsy, extracorporeal lithotripsy) while in the control group residual concrements were in 10 (14.9%) patients, 7 of them (10.4%) were reoperated. Thus, complete concrements evacuation from the upper urinary tract was achieved in 80.5 and 85.1%, respectively. Mean duration of the operation was 66.4 and 72.6 min, respectively; mean bed occupancy was 9.3 and 9.1 day, respectively. Complications in both groups consisted for the most part of postoperative hematuria and exacerbation ofpyelonephritis. No injuries of the adjacent organs were registered. Thus, PNLT in dorsal position is an effective and safe treatment of nephrolithiasis, especially in patients with obesity, bone lesions and severe concomitant diseases.

[Doppler technologies in combined diagnosis of acute pyelonephritis]

We studied diagnostic potentialities of conventional clinical, device, x-ray and ultrasonic methods including current Doppler technology in differentiation of serous and purulent stages of acute pyelonephritis (AP) in 50 patients (mean age 25.5 +/- 5.5 years). Energetic dopplerangiography (EDA) showed the highest diagnostic significance. EDA was highly informative in renal carbuncle and total purulent destruction of the kidney and low informative in serous and apostematous AP, renal abscess. Conventional ultrasonic, x-ray, clinical and device investigations as well as impulse dopplerography and color Doppler mapping of blood flow are of secondary importance in AP.

[Using energetic Doppler-angiography in combined diagnostics of prostatic abscess]

Diagnostic possibilities of conventional clinical-laboratory, physical methods, seroscale echography and energetic dopplerangiography (EDA) were compared in 32 patients with prostatic abscess (PA). Nonspecific symptoms hamper conventional PA diagnosis. PA is detected, as a rule, at transrectal ultrasonic investigation (TUI) which is effective in formed PA (sensitivity 100%) but is low effective in early PA (sensitivity 50%). Minimal size of PA detectable by TUI is 7 mm (mean 12 +/- 1.2 mm). EDA improves diagnostic potential of TUI in infiltrative PA (sensitivity 91.7%). In established PA, EDA confirms TUI findings. Transabdominal ultrasonography has insufficient resolution and must be used for PA screening.