[Long-term results of ureteral replacement using small bowel in patients with long strictures: 9-years single-center experience]

INTRODUCTION

When reconstructing long ureteral strictures, the optimal substitution material is reconfigured pelvis or bladder flaps. However, it is not always possible to use them due to involvement in the pathological process or insufficient length to replace the defect. In such cases, substitution of the ureter by ileal segment is successfully used.

MATERIALS AND METHODS

A total of 25 patients, 10 men (40%) and 15 women (60%), who undergone to reconstructive procedure during the period from 2012 to 2021 with a follow-up period of at least 6 months (mean 51.26 months) were included in the retrospective analysis. Additionally, a comparative analysis was carried out between the laparoscopic and open access according to a set of criteria. The endpoints in the study were the functional state of the kidneys, repeated procedures and development of metabolic disorders.

RESULTS

The average length of the stricture was 10.7 cm (5-20 cm). Eleven patients underwent open approach (44%), while in 14 cases laparoscopic approach was used (56%). Primary procedure was performed in 16 (64%) patients, repeated intervention due to stricture recurrence was performed in 7 (28%) cases, and two patients (8%) underwent bowel substitution of the ureter, implanted into the ileal conduit after radical cystectomy. The average duration of the procedure was 240 min (Q1-186 min, Q3-307 min). For laparoscopic access it was 230 min (Q1-186 min, Q3-292 min) compared to 240 min (Q1-202 min, Q3- 312 min) for open access. Complications of the Clavien I grade developed in 5 cases (20%). With a minimally invasive approach, the length of stay in hospital was 6 days (5-6), including 0.7 days (0-1) in the intensive care unit. The average number of drains after laparoscopic procedure was 1.3 (0-2), and the drains were removed in average after 4.4 days (3-5). With open access, the median length of stay was 8 (5-11), including 2 days (1-5) in the intensive care unit. The number of drains was 1.6 (1-2), and the drains were removed in average after 4 days (3-5). Thirteen patients were undergone to follow-up examination until discharge. Regression of dilatation of the pelvicaliceal system was noted in 12 patients (92.3%). Among them, renal function stabilized in 8 (61.5%), improved in 4 (30.8%) and deteriorated in 1 case (7.7%). Clinically significant metabolic acidosis was detected in 1 patient (7.7%).

CONCLUSION

Substitution of the ureter by ileal segment showed satisfactory results in long-term follow-up.

[Mean features of the nephron- sparing surgery in older patients with localized renal cell carcinoma]

BACKGROUND

Imaging diagnostics becomes more widespread, the incidence of incidental renal cell carcinoma (RCC) among older adults is increasing each year. Although nephron-sparing surgery are the standard of care for localized RCC, the potential risk of perioperative complications and readmission rates are higher among older patients.

OBJECTIVE

To compare the main perioperative indicators, as well as oncological and functional results in the treatment of localized RCC in in older patients and middle-aged patients MATERIALS AND METHODS: From 2016 to August 2021 at the N.I. Pirogov Russian National Research Medical University on the basis of N.I. Pirogov City Clinical Hospital No. 1 we performed 134 laparoscopic PN. The 1st group included patients from 55 to 69 years old - 96 (71.6%) and 2nd group - 70 years and older - 38 (28.4%). The physical status was assessed according to the ASA (American Society of Anesthesiologists) classification and the Charlson comorbidity index (IC) was calculated. Glomerular filtration rate (GFR) was estimated using the MDRD (Modification of diet in renal disease) formula.

RESULTS

Length of the operation in patients in 1st group was 133.1 minutes. (60-250), in 2nd group 139.3 (50-240), the median time of warm ischemia was 12.4 (7-33) and 12.7 (6-22) minutes, the median blood loss volume was 123.3 and 135.1 ml, respectively. Complications, according to the Clavien-Dindo classification, were in 21 (21.9%) cases in patients from 55 to 69 years old and in 9 (23.7%) in patients 70 years and older. The median GFR for MDRD in the postoperative period for groups I and II was 57.4 and 50.5 ml/min/1.73 m2. The median follow-up time was 26 (4-66) months. A positive surgical margin was observed in 2 (2.1%) cases in the 1st group and in 1 (2,6%) in 2nd group. The median follow-up time was 26 (4-66) months.

CONCLUSION

Nephron-sparing surgery is safety in patients 70 years and older and the main intraoperative and oncological results are comparable to the group of middle-aged patients. Age itself is not a contraindication to surgical treatment.

[Pathomorphological aspects of urethral strictures of various etiologies]

INTRODUCTION

The study of the structure of strictures of various etiologies is an open and uncertain issue of modern urology.

AIM

To evaluate the morphological and immunohistochemical structure of strictures of various etiologies.

MATERIALS AND METHODS

The study involved postoperative tissue of a pathologically altered urethra of 110 patients aged 23 to 74 years who underwent treatment at the University Clinic of Urology, Russian National Research Medical University. N.I. Pirogova (2014-2018) with Ds: urethral stricture. Morphological study: Van-Gieson staining; hemotoxylin - eosin. Immunohistochemical study: mouse monoclonal antibodies to muscle and connective tissue markers (Smooth Muscle Actin, Vimentin, Calponin) and inflammation markers (CD45R, CD58, CD138, CD20, CD3) were used as primary antibodies in all reactions.

RESULTS

According to the revealed morphological changes, the material was divided into three groups: group I (n=27) - active inflammation; group II (n=33) - the predominant development of connective tissue with low activity of inflammation; group III (n=50) - mixed (chronic mild inflammation, an even amount of connective tissue). In a morphological study of idiopathic urethral strictures, it was noted that the multicolumnar epithelium was replaced by a multi-layer flat epithelium with a weakly pronounced keratinization. Inflammatory changes were mild, including the submucosal connective tissue and the spongy body. Spongiofibrosis is accompanied by a significant reduction in the vascular bed of both venous sinuses and arteries. The same changes were observed in the inflammatory genesis of urethral strictures. In the study of strictures with traumatic etiology, a restructuring of the cylindrical epithelium was observed. In cases with severe inflammation in the mucosa, the changes were atrophic-hyperplastic in nature with reactive cell atypia.

CONCLUSION

urethral Strictures in men have a specific etiological factor, but the pathogenesis of urethral lesions can be divided into: post-traumatic and post-inflammatory.

[The problem of antibiotic resistance in patients with urinary tract infection]

OBJECTIVE

To analyze the incidence and resistance of microorganisms to antibacterial drugs isolated in urine cultures of patients with urinary tract infections from 2012 to 2019.

MATERIALS AND METHODS

In the Pirogov City Clinical Hospital No1 and in the Bauman City Clinical Hospital No 29 analyzed the results of 15083 urine cultures in 12554 patients from 2012 to 2019.

RESULTS

Enterococcus faecalis (41%), Escherichia coli (36.4%), Klebsiella pneumonia (23.4%) and Proteus mirabilis (7.6%) predominate in the occurrence of complicated UTIs. the number of strains resistant to certain groups of antibacterial drugs increased: mesitillin-resistant staphylococci (+ 4%), producers of -lactamases (+ 19.8% (for E. coli) and + 34.7% (for Klebsiella pneumoniae)), vancomycin-resistant enterococci (+ 1.89%), carbapenemase producers (+ 32.9%). A high level of resistance among Enterococcus faecalis strains to ciprofloxacin (23.1%) and gentamicin (38.4%) was revealed. Among strains of Escherichia coli, an increase in resistance to ampicillin (85.7%), ceftazidime (66.7%), ciprofloxacin (54.1%) and nitrofurantoin (42.9%) was noted. The appearance of carbapenem-resistant strains is noted. Among the strains of Klebsiella pneumonia, there is a significant increase in resistance to all antibacterial drugs used. Separately, one can note a sharp (27.1%) increase in resistance to carbapenems. A high level of resistance was found in Proteus mirabilis to ciprofloxacin (66.7%), ampicillin (75%). There is an increase in resistance of Pseudomonas aeruginosa to ciprofloxacin (66.7%), meropenem (50%). There is a high level of resistance for Acinetobacter baumannii to amikacin (94.9%), imipenem (92.3%), ceftazadime (100%), ciprofloxacin (100%), tigecycline (53.6%). Relatively high sensitivity remains to polymyxin E (88.9%).

CONCLUSIONS

The results of our analysis demonstrate a rapid increase in resistance to most antibacterial drugs among community-acquired and hospital-acquired strains.

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

AIM

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

MATERIALS AND METHODS

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

RESULTS

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

CONCLUSION

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

[Surgical technique and the first clinical experience of augmentation urethroplasty without dividing of corpus spongiosum (KODAMA technique)]

AIM

In case of complex and long urethral stricture a use of augmentation technique is often limited by "critically" narrowing of urethral plate. In such cases, the augmentation anastomotic urethroplasty without division of the corpus spongiosum can be the method of choice, because it allows to perform simultaneous augmentation urethroplasty with maximal sparing of antegrade blood flow in corpus spongiosum.

MATERIALS AND METHODS

In urologic clinic of N.I. Pirogov City Clinical Hospital No1 the analysis of 17 patients who were undergone to augmentation anastomotic urethroplasty without division of the corpus spongiosum (Kodama technique), performed by single surgeon from 2013 to 2017 yy was done. The meant stricture length was 3.75 cm (2-6). Penile, bulbar and panurethral stricture was found in 6 (35.3%), 7 (41.2%) and 4 (23.5%) cases, respectively.

RESULTS

Technique efficiency was 88.2% and in 2 patients (11.8%) a stricture recurrence developed. The mean maximum flow rate before and after surgery were 5.4 and 23.1 ml/s, respectively (p<0.05). The mean catheterization time was 14 (7-30) days. There were no patients with de novo urinary incontinence and erectile dysfunction.

CONCLUSION

The initial results of augmentation anastomotic urethroplasty without division of the corpus spongiosum showed high efficiency. To our opinion, the antegrade blood flow sparing makes it the method of choice in patients with long non-traumatic urethral stricture (without severe spongiofibrosis), good preoperative erectile function but isolated length of "critically" narrowing of the urethral lumen.

[Iatrogenic urethral structures in men]

INTRODUCTION

Iatrogenic urethral damage is the leading etiologic factor for urethral stricture in men in developed countries and second after traumatic injury in developing ones. This study aimed to evaluate the frequency of iatrogenic strictures of the urethra and the results of their treatment.

MATERIALS AND METHODS

This retrospective analysis comprised 133 patients who were treated for iatrogenic urethral stricture from 2011to 2016. Group I included 72 (54%) patients after trans(intra)urethral interventions (transurethral resection of the prostate or urinary bladder), urethral dilation, traumatic catheterization, etc. Forty-five (34%) patients with post-catheter strictures (ischemic/post-inflammatory), 7 (5%) patients after failed treatment of hypospadias, and 9 (7%) patients after open adenomectomy made up groups II, III, and IV. The diagnosis of recurrent stricture and the need for repeat surgical intervention were determined based on uroflowmetry, urethrography, and urethrocystoscopy.

RESULTS

In group I, the mean extent (rank) of the stricture was 2 (0.1-15) cm, the most frequent location (85%) was the bulbar urethra. In group II, the most frequent location (71%) was also the bulbar urethra with a mean stricture length of 2.4 (0.3-13) cm. There were 4 cases of panurethral strictures, lesions of the penile urethra and meatal stenosis. In group III, the strictures were on average 6 (2-12) cm long. Patients group IV had strictures of the bulbar and prostatic urethra. In general, the effectiveness of endoscopic treatment (direct vision internal urethrotomy, DVIU) was 52%, the effectiveness of urethroplasty varied from 83 to 100% depending on the method. In group I, the effectiveness of the DVIU was 52%, various types of urethroplasty - 88-100%, in group II - 50% and 82-100%, respectively. In group III, the effectiveness of the single-stage/multi-stage buccal mucosa urethroplasty was estimated at 0%/100%. In group IV, the effectiveness of DVIU/urethroplasty/perineal prostatectomy was 20%/75%/100%.

CONCLUSION

The proportion of iatrogenic urethral strictures in large megacities can reach 45%. Iatrogenic urethral strictures most commonly result from catheterization and transurethral interventions. Each subgroup of iatrogenic strictures is characterized by its location, extent and degree of urethral spongiofibrosis. With the correct choice of surgical modality, urethroplasty is almost twice more effective than DVIU.

[Clinical Case of Successful Nephrectomy and Stenting of the Coronary Arteries in Acute Period of Myocardial Infarction in a Patient With Kidney Cancer]

We describe in this case report the clinical situation of development of massive macrohematuria at the background of dual antiplatelet therapy in a patient in the acute period of myocardial infarction with an established diagnosis of kidney cancer and a burdened cardiac anamnesis. Despite the high anesthetic and operational risk of complications, due to the need for coronary angiography with possible stenting of the coronary arteries, left ventricular thrombus and the impossibility of canceling antiplatelet agents and anticoagulants, the patient underwent radical nephrureterectomy, which allowed further stenting of the anterior interventricular artery occlusion and thus to reduce the risk of developing a repeated myocardial infarction.

[Quality of life in women after anterior pelvic exenteration]

60 women, who underwent anterior pelvic exenteration with different types of urine derivation since 2004 till 2014 years in urology department, RMAPO, S.P. Botkin city hospital, were included in retrospective investigation. Middle age of patients was 53,2+/-3 (32-68). 38 women with bladder cancer and 22 women with urinary injuries after radiation therapy underwent anterior pelvic exenteration. Aim of this work is to perform quality of life comparison of patients after anterior pelvic exenteration with different types of urine derivation. Patients were divided in 3 groups: 1-st group 39 (65%) women, who underwent Brickers operation, 2-nd group 19 (31,66% ) women, who had Studers operation and 3-rd group - 2 (3,34%), patients who underwent continent urine derivation with formation of catheterizing urinary reservoir. Questionnaire (SF-36) was used to evaluate quality of life. Observation period was from 2 to 10 years. Postsurgical lethality was 3%, 5-years survival rate was 60,9+/-15,8% and 5-years recurrence-free survival rate was 55,4+/-12,6%. We established that quality of life in women who underwent orthotopic urine derivation was higher than in patients who underwent incontinent ileoconduit formation. Better quality of life was demonstrated by women, who had catheterizing urinary reservoir, but it is difficult to compare this group with the others, because of small number of patients with heterotopic catheterizing reservoir. Regarding the results of our investigation we made next conclusions: In spite of difficult technique, high risk of postoperative complications and lethality, anterior pelvic exenteration provide 5-years survival rate for 70% of patients In locally advanced tumors of pelvic organs anterior pelvic exenteration is salvational operation and keep satisfactory quality of life Orthotopic intestinal urine derivation is better to provide satisfactory quality of life for patients with invasive bladder cancer. For women with urinary injuries after radiation therapy Brikers operation is better type of urine derivation, in special cases heterotopic catheterizing reservoirs can be made.

[10 YEARS' EXPERIENCE IN USING DIRECT URETEROINTESTINAL ANASTOMOSIS IN URINARY INTESTINAL DIVERSION AFTER RADICAL AND SIMPLE CYSTECTOMY]

147 patients who underwent urinary intestinal diversion from 2004 to 2014 were selected for the retrospective study. The authors carried out a comparative analysis of rates of complications that arise from the direct ureterointestinal anastomosis. The mean age of patients was 54.2 ± 3.0 (36-69) years. 60 (40.81%) patients of group 1 underwent Nesbit's direct ureterointestinal anastomosis, while in 87 (59.19%) patients of group 2 Wallace-1 and Wallace-2 anastomoses were performed. Average follow-up was 5.6 (2-10) years. Strictures of ureterointestinal anastomosis were detected in 2 (3.38%) patients of group 1 and in 1 (1.14%) patient of group 2. In all cases re-anastomosis was performed. The maximum postoperative concentration of serum creatinine in both groups was 231 mmol/l. According to radioisotope kidney scan, no differences in accumulative and excretory renal functions between two groups of patients were recorded. No kidney stone formation in both groups of patients during the follow-up period was observed. No ureteral reflux above grade 3 was noted. The clinical manifestation of reflux pyelonephritis was observed in 3.5% of the patients. Acute pyelonephritis was cured by antibacterial therapy.

[Simultaneous radical retropubic prostatectomy, diverticulectomy]

Presented clinical case demonstrates a combination of rare congenital abnormality - giant true diverticula of the bladder - and high-risk prostate cancer, as well as a successful result of simultaneous operation - a radical prostatectomy with diverticulectomy.