[Results of percutaneous nephrolithotomy using two accesses in the treatment of patients with staghorn stones]

INTRODUCTION

In order to improve clinical efficiency and reduce the risk of postoperative complications in patients with staghorn stones, we compared the results of original technique of biportal percutaneous nephrolithotomy (PCNL) with the standard PCNL.

MATERIALS AND METHODS

The total of 221 patients with staghorn stones of K3-K4 was included in the study. The biportal PCNL was used in 109 patients, while the control group consisted of 112 patients. Inclusion criteria were stone size more or equal 2 cm, age over 18 years, absence of coagulopathy and width of the renal parenchyma more or equal 1 cm. On 1st postoperative day, ultrasound or plain urography was performed, while in patient with radiolucent stones, multi-slice computed tomography was used. In addition, complete blood count and biochemical profile were done. The main difference from the standard PCNL with sequential renal tracts is the simultaneous creation of the main and additional accesses when performing biportal PCNL. This method allowed two surgeons to simultaneously and synergistically perform lithotripsy and stone extraction from two accesses using a standard nephroscope in the main tract of 24 Ch and a miniaturized nephroscope in the additional tract of 16.5 Ch.

RESULTS

The stone-free rate in the group of biportal PCNL was 80.7% (n=88), compared to 72.3% in the control group (n=81). Secondary interventions and additional procedures were required in 29 (26.6%) and 40 (39.2%) cases, respectively. The total number of infectious and hemorrhagic complications was higher in the control group.

DISCUSSION

According to our data, significant advantages are observed in the group of biportal PCNL compared to the standard technique.

CONCLUSION

Biportal PCNL can be recommended as a promising advancement of the technique traditionally used in the clinical practice.

[Bacteriophage Therapy of Urological Infections]

A literature review dedicated to the problem of bacteriophage therapy for infectious and inflammatory diseases, including urological infections, is presented. Considering the growth of antibiotic resistance, the search for alternative treatments is relevant. Current data about bacteriophages and mechanism of their action, difference of virulent and temperate phages is given, as well as mechanisms of bacteria resistance to phages and ways of its overcoming. The history of phage therapy for infectious diseases from the beginning of the 20th century to the present days is presented. Pharmacokinetic studies of phages after oral administration are given. Moreover, we described our 30 years experience on of clinical use of bacteriophage cocktails in the treatment and prevention of urological infection. In addition, problems of phage therapy are discussed, including immunological issues and the advantages of bacteriophages over antibiotics.

[Prevention of infectious and inflammatory complications after percutaneous nephrolithotomy]

INTRODUCTION

Given the increase in antibiotic resistance of uropathogens, one of the urgent problems is a development of optimal antimicrobial prophylaxis for surgical interventions, as well as an adequate regimen of antibiotic therapy after percutaneous nephrolithotomy (PCNL).

AIM

to determine an effective perioperative antimicrobial prophylaxis for PCNL in patients with kidney stones.

MATERIAL AND METHODS

A total of 90 patients with staghorn or multiple large kidney stones who underwent PCNL were included in the study. Before PCNL, urine culture was performed in all patients in order to determine the sensitivity not only to antibiotics, but also to bacteriophages. In addition, urine was taken for additional microbiological studies after the puncture of the collecting system, as well as on the 3rd and 7th day after PCNL. All patients were divided into three groups of 30 patients depending on the regimen of perioperative prophylaxis. In group 1, patients were prescribed ciprofloxacin 1000 mg i.v. intraoperatively, then 1000 mg i.v. q.d. for 3-5 days. In the group 2, patients received one dose of cefotaxime + sulbactam (1.0 g + 0.5 g) 2 hours before PCNL i.m. In the group 3, a polyvalent pyobacteriophage purified was given orally 1 hour before PCNL in a dose of 40 ml and the same dose was used t.i.d. for 3-5 days postoperatively.

RESULTS

In all three groups of patients, the following infectious complications were evaluated: acute pyelonephritis, systemic inflammatory response syndrome (SIRS) and urosepsis. There were no serious infectious and inflammatory complications in the early postoperative period among all patients. SIRS developed on days 1-3 after PCNL in 26.6%, 20% and 20% of patients in group 1, 2 and 3, respectively. However, by days 4-7 after PCNL, there was normalization of blood cells count (leukocytes, neutrophil band cells), temperature and general condition.

CONCLUSION

Different regimens of antimicrobial prophylaxis for PCNL have the same efficiency. The development of SIRS on days 1-3 after PCNL is correlated not only with the antimicrobial agents used and the route of their administration (intravenously, intramuscularly and orally). Most likely, the development of SIRS is more associated with surgical trauma.

[Effectiveness of laparoscopic repair of primary strictures of ureteropelvic junction]

AIM

To evaluate the effectiveness of laparoscopic repair of primary strictures of ureteropelvic junction (UPJ) depending on baseline renal function of the ipsilateral kidney.

MATERIALS AND METHODS

The study analyzed results of 134 patients (78 women and 56 men, age from 18 to 56 years) who underwent various types of laparoscopic repair of the UPJ stricture from 2012 to 2015. Depending on the surgical technique all patients were divided into three groups: group 1 (n=34) underwent spiral flap technique by Culp and DeWeerd, group 2 (n=59) - Anderson-Hynes pyeloplasty and group 3 (n=41) had antevasal dismembered pyeloplasty. All interventions ended with internal ureteral stenting for up to 6-8 weeks. Also, all patients were divided into three subgroups, depending on the degree of renal function deficiency - less than 25%, 25-50%, and 51-75%. Treatment effectiveness criteria included the following parameters: complete relief of the pain syndrome, a decrease in the degree of pyeloectasia, stabilization or improvement of the functional state of the renal parenchyma (according to radioisotope renography), and the absence of recurrence of the UPJ stricture.

RESULTS

The overall effectiveness of UPJ laparoscopic reconstruction was 94.7% (127 of 134). The effectiveness of the treatment was independent of the surgical technique, the initial thickness of the renal parenchyma and the degree of PCS dilatation. There was an inverse correlation between the treatment effectiveness the degree of kidney function deficiency.

CONCLUSION

In patients with hydronephrosis secondary to UPJ stricture, the effectiveness of surgical treatment is mainly determined by its timeliness. The best treatment results were observed in patients with better renal function. The degree of renal function deficiency should be considered the main prognostic factor for the effectiveness of the forthcoming operation.

[Mechanism of action and efficacy of litium chloride in thermal ischemia of the kidney]

A protective effect of lithium chloride (LC) in thermal ischemia of the kidney of different duration was studied in rats. LC efficacy was estimated by functional activity of ischemic kidney in early and late reperfusion period, by damage to mitochondria of tubular epithelial cells and production of active oxygen forms (AOF) and nitric oxide (NO). LC has a marked anti-ischemic effect. In thermal renal ischemia for 40 and 60 min LC provides functional safety of the ischemic organ. In longer ischemia, 50% of the animals died. The mechanism of the protective action of LC is related to reduction of APK production, support of a high transmembrane potential of mitochondria and NO synthesis redistribution in the cells of tubular epithelium cells.

[Clinicobiochemical study of diagnostic value of the panel including 10 potential protein markers of prostatic cancer]

We tested diagnostic value of the panel of 10 specially selected proteins--potential markers of prostatic cancer. A double blind method and proteomic technologies were used in complex clinicobiochemical examination of 20 patients with benign and malignant tumors. The same diagnosis were obtained by clinicomorphological criteria and protein markers in 13 (65%) cases. The highest diagnostic efficacy was achieved in prostatic cancer--11 cases (79%) vs 14 by clinicomorphological criteria.

The role of mitochondria in oxidative and nitrosative stress during ischemia/reperfusion in the rat kidney

Reoxygenation following ischemia causes tissue oxidative stress. We studied the role of oxidative stress caused by kidney ischemia/reperfusion (I/R) on the mitochondria of renal tissue slices. I/R caused the mitochondria to be swollen, fragmented, and have lower membrane potential. The mitochondria generated more reactive oxygen species (ROS) and nitric oxide (NO) in situ as measured by fluorescence of ROS- and NO-sensitive probes. Infusion of lithium ion, an inhibitor of glycogen kinase synthase-3, caused phosphorylation of its Ser-9 and restored the membrane potential and decreased ROS production of the mitochondrial fraction. Ischemic kidney and hypoxic rat preconditioning improved mitochondrial membrane potential and lowered ROS production caused by subsequent I/R similar to lithium ion infusion. Preconditioning normalized NO production in mitochondria as well. The drop in the mitochondrial membrane potential was prevented by NO synthase inhibition, demonstrating a strong contribution of NO to changes in mitochondrial energy metabolism during the I/R transition. Mitochondria in the I/R-stressed kidney contained less cytochrome c and more pro-apoptotic Bax, consistent with apoptotic degradation.

[Application of cell technologies for therapy of chronic renal insufficiency (experimental study)]

The experiments on 29 white non-inbred rats with chronic renal failure (CRF) induced by right-side nephrectomy and coagulation of 1/2-2/3 of parenchyma of the left kidney were made to study the trend in renal function after injection (into renal cortex or intravenously) of cultured stem or progenitor cells from human fetuses (total culture of fetal kidney or mesenchymal stem cells of the bone marrow). In control tests with salt solution functional indices reflected persistence of CRF. On day 4 after introduction of the fetal cells into renal parenchyma renal function improved and normalized in 2 weeks. After intravenous injection of fetal cells CRF reduced slowly, especially after injection of medullary mesenchymal cells with normalization in 1 month. 2.5-3.5 months after the injection test parameters in some rats deteriorated but remained close to normal values. Glomerular filtration after injection of stem and progenitor cells recovered better while canalicular sodium reabsorption underwent normalization but was followed by deterioration.

[New approaches to molecular diagnosis of prostatic cancer]

We compared prostatic proteins in patients operated for adenoma or cancer. 630 protein fractions were obtained from each tissue sample after fractionation by two-dimentional electrophoresis according to O'Farrell. Comparison of the samples from adenoma and cancer showed their difference by 7 proteins among which were isoforms of glyceraldehydes-3-phosphate-dehydrogenase, alpha-collagen and several little known proteins. Most of the cancer patients had the protein with molecular mass 19 kDa and isoelectric point 9.0. By the results of mass-spectrometry this protein was identified as androgen-induced secreted protein AGR2. This protein is considered a potential oncomarker. Prospects of some postgenome technologies for detection of new diagnostic markers of prostatic cancer are discussed.

[The role of the mitochondria generating reactive oxygen species and nitric oxide in postischemic functional disturbance of the kidney]

Experiments on 10 rats and 10 rabbits were made to investigate metabolic aftereffects of 40-minute heat ischemia and subsequent reperfusion. It was found that mitochondrial function deteriorated significantly in an early postischemic period. The disorder manifested with a relative prevalence of cell ATP consumption over its synthesis. This is accompanied with intensive production by mitochondria of nitric oxide and oxygen free radicals. Fluorescent probes and confocal microscopy of vital renal sections showed that mitochondria are responsible for excessive generation of nitric oxide and oxygen radicals in the kidney in an early reperfusion period. The discussion concerns the role of nitric oxide in reperfusion renal damage and participation of mitochondria in formation of its anti-ischemic resistance.

[Identification of AGR2 protein, a novel potential cancer marker, using proteomics technologies]

A comparative analysis of the proteins in prostate tissues of the patients operated for hyperplasia (n = 7) or cancer (n = 5) was performed aiming to search for protein diagnostic markers. Differences in several minor proteins were detected using two-dimensional electrophoresis according to O'Farrel; among them, an additional protein with a molecular weight of 19 kDa and an isoelectric point of 9.0 was observed in four of the cancer cases. Mass spectrometry allowed this protein to be identified as the androgen-induced secreted protein AGR2. The possibility of using AGR2 as a diagnostic marker of prostate cancer is discussed.

Functional aftereffects of intraparenchymatous injection of human fetal stem and progenitor cells to rats with chronic and acute renal failure

Chronic renal insufficiency was modeled in rats by unilateral nephrectomy and electrocoagulation of both poles of the remaining kidney; acute renal failure was induced by 90-min clamping of the vascular pedicle of the only kidney. Injection of unfractionated culture of human fetal kidney cells or bone marrow mesenchymal stem cells into damaged kidney restored its function in rats with chronic renal insufficiency (observation period up to 2 months). After 2.5 months a relapse of chronic renal insufficiency was observed in 1 of 3 rats receiving human fetal kidney cells and in 1 of 2 animals receiving bone marrow mesenchymal stem cell culture. Injection of bone marrow mesenchymal stem cell culture to rats with acute renal failure improved recovery of renal function and prevented the death from uremia, while injection of total culture of human fetal kidney cells had virtually no effect on the course of acute renal failure.

[Quality of life of elderly patients with nephrolithiasis]

Clinical findings have been analysed for 105 presenile and senile patients with nephrolithiasis. A total of 168 operations have been made: open intervention (n=22), percutaneous nephrolitholapaxia (n=12), extracorporeal lithotripsy (n=134). Quality of life was assessed according to the questionnaire survey (an original visual graphic questionnaire on the patient's attitude to his/her disease and the treatment, questionnaire on the doses of analgetics and antibiotics, conventional questionnaire EQ-SD. It was found that elderly patients note a statistically significant fall in frequency of pains (renal colics, lumbar pains, subfebrile condition), in the dose of analgetics and antibacterial drugs 6-12 months after removal of the concrement. Removal of the concrement had a positive influence on quality of life of patients with urolithiasis. Extracorporeal lithotripsy had a weaker emotional effect on the patients than open surgical interventions. It is suggested to remove nephroliths if contraindications are absent.

[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.

[Complications of open surgical procedures in urolithiasis and their prevention]

236 operative interventions for urolithiasis have been performed in 234 patients. Of them, 187 (79.9%) patients developed complications. Intraoperatively complications resulted from opening of the pleural and abdominal cavities (20 patients, 8.5%) and intraoperative blood loss < 500 ml (19 patients, 8.1%). In one case a nephrectomy was made because of repeated hemorrhage early after the operation. Among the postoperative complications most frequent were acute pyelonephritis (34, 14.5%) and aggravation of renal failure (11, 4.7%). The former demanded extracorporeal detoxication in 9 cases, in the latter hemodialysis was not required. Residual comcrements occurred in 28 (12%) patients. 17 of them had to undergo extracorporeal lithotripsy. Thus, open urological interventions in urolithiasis are now conducted in advanced disease, provoking complications. This raises responsibility of the surgeons who must take maximal preventive measures and use novel technologies in management of the complications.

[Extracorporeal shock-wave lithotripsy (ESWL) in removal of stones in anomalies of kidney and upper urinary tracts]

The authors analyze the results of ESWL (URAT-P unit) for urolithiasis performed in 106 patients (49 females and 57 males) aged 16-67 years with anomalous kidneys and upper urinary tracts. 28, 1, 11, 14, 24, 4, 22 and 2 patients had horseshoe, L-shape, solitary, lumbar distopic, double, sponge, cystic kidneys, congenital megacallicosis, respectively. The stones ranged in size from 7 to 30 mm. Bilateral urolithiasis was in 7 patients. The number of impulses averaged 1745 +/- 168.4 per the procedure. The average number of ESWL procedures per stone was 1.4 (1-4). The stones were completely eliminated after one ESWL session in 78(73.6) patients, after two sessions in 23(21.7%) patients, after three sessions in 4, after for in 1 patient. Complications developed in 18 patients: urinary tract obstruction and attack of acute pyelonephritis (15 and 3 patients, respectively). Within 2-10-year follow-up recurrences arose in 12 patients who were retreated. Thus, ESWL is a method of choice in the treatment of urolithiasis patients with malformations of the kidneys and upper urinary tracts. Good results of ESWL are achieved in strict adherence to principles of the patients' selection, preoperative preparation technique, individual approach to patients in postoperative period, follow-up to detect complications and recurrences.

[Ways of prevention of kidney lesions during nephrolithotomy or extracorporeal lithotripsy in nephrolithiasis]

Outcomes of nephrolithiasis treatment depend not only on renal dysfunction resultant from abnormal urine passage and concomitant infection but also on intraoperative mechanical trauma and ischemia. To compare renal damage induced by nephrolithotomy with that of shock-wave lithotripsy and effects of chemotherapy, 54 patients with nephrolithiasis were divided into 2 groups and 2 subgroups. Patients of group 1 underwent nephrolithotomy, those of group 2--extracorporeal shock-wave lithotripsy (ESWL). Subgroups "a" in both groups received no chemotherapy, subgroups "b" were treated with alpha-tocopherol, pentoxifylline, indomethacin. ESWL was found less traumatic. Postoperative drug prophylaxis promoted more pronounced inhibition of lipid peroxidation products and urinary enzymes activity, contributing to lessening of the operative trauma. Anti-ischemic protection of the kidneys also improved renal function.

[Changes in the oxygen tension of the kidney cortex in exposure to laser irradiation at different wavelengths (an experimental study)]

Experiments with exposure of the renal cortex to different kinds of laser radiation with measurement of pO2 demonstrated that intravenous UV laser radiation inhibits tissue oxygenation. Subvascular blood exposure to infrared and intravenous one to He-Ne laser are beneficial as such radiations improve oxygenation of the renal cortex.

[The comparative characteristics of the effect of continuous ischemia and ischemia with periodic reperfusions on the function and metabolic indices of the rabbit kidney]

Continuous 40-min ischemia and ischemia with reperfusion (10 min of ischemia and 10 min of reperfusion) induced by ligation of the vascular kidney crus were compared in experiments on 17 New Zealand rabbits. Both in continuous and interrupted (in period 4) ischemia resulted in the growth of pO2 cortical layer which is likely to be due to reduced oxygen utilization of the cells caused by metabolic and renal function disorders. Examination of lipid peroxidation activity determined similar activation of this process in both ischemic variants. In spite of the fact that both continuous and interrupted ischemias induced similar hyperoxygenation of the cortical substance and the same activation of lipid peroxidation, functional damage was less severe in experiments with interrupted ischemia.