[Integrative approaches to the diagnosis and treatment in urology].

Modern medical science is characterized by the rapid development of diagnostic equipment, the introduction of more sophisticated and science-based technology in the diagnosis and treatment of diseases. Features of the urologist's work in the modern world and the diversity of manifestations of urologic diseases require close cooperation between physicians of different specialties. Interdisciplinary cooperation is necessary and urgent not only for professionals but also for patients. The authors summarize and present the problems that connect urologists with colleagues in medicine, biology, and other areas of our life.

[Modern aspects of classification of the complications of extracorporeal shock wave lithotripsy].

Postoperative complications of extracorporeal shock wave lithotripsy (ESWL) develops due to inadequate assessment of the clinical course of urolithiasis, incorrectly defined indications for treatment, lack of adequate preoperative preparation and ESWL technology. Based on the analysis of the results of treatment of 4500 patients with urolithiasis in the Clinic of Urology of the First MSMU n.a. I.M. Sechenov, taking into account the Clavien-Dindo classification of postoperative complications, we proposed a classification of complications of extracorporeal shock wave lithotripsy, which allows to estimate the degree of complications and determine the sequence of the provision of special medical care.

[Hormonal and metabolic disorders as systemic factor for the formation of urinary calculi].

In patients suffering from urolithiasis, metabolic diagnostics often reveals abnormalities contributing to the formation of stones: hypocitraturia, hyper- and hypocalcemia, hypercalciuria, hypomagnesemia/hypomagnesuria, hyperoxalaturia, etc. Before surgery, complex biochemical examination of blood and 24-hourcollection urine in 82 patients with urolithiasis was performed. The analysis of the main laboratory parameters of carbohydrate, lipid, calcium and phosphorus and purine metabolism found the prevalence of violations of calcium and phosphorus metabolism in these patients. Dyslipidemia was diagnosed in 31 (37.8%) patients. There was a significant positive correlation between serum total cholesterol and serum total calcium (rs = 0.3315, P = 0.0103). Low serum calcium levels were associated with hyperoxalaturia (rs = -0.4270, P = 0.0295). There was a significant effect of natriuria on urinary excretion of oxalate (rs = 0.6107, P = 0.0001), Mg (rs = 0.4156, P = 0.0096) and K (rs = 0.5234, P = 0.00005). The study shows the role of magnesium in the prevention of recurrence and manifestation of urolithiasis. The combination of two or more types of hormonal and metabolic disorders increases the incidence of recurrent stones. Timely correction of hormonal-metabolic status allows to reduce the risk of stone formation, and hospitalization attributable to the complications associated.

[Mitomycin in the complex treatment of strictures of vesicourethral anastomosis after radical prostatectomy].

The study involved 189 patients aged 40 to 80 years, which underwent retropubic radical prostatectomy for localized prostate cancer in the period from 2009 to 2013. 26 (13.8%) patients required repeated surgery due to the deterioration of urination. In primary detection or recurrent nature of the cicatrical process in vesico-urethral anastomosis, in places of dissection by urethrotomic knife (or transurethral resection), surgery was complemented by submucosal injection of mitomycin, previously diluted in saline to a concentration of not more than 0.2 mg/ml. Effectiveness of additional interstitial administration of mitomycin in primary application was 85%. Systemic infusion reactions have not been reported, that allows to consider this method as safe method for prevention of cicatricial complications.

[Modern conservative (citrate) therapy for urate calculi in the ureters].

The results of conservative citrate therapy of 35 patients with urate calculi in ureter are presented. Due to the violation of the passage of urine in the upper urinary tract, the vast majority of patients (31 (88%)) underwent ureteral stenting to restore adequate flow of urine before treatment. In four patients, drainage of the upper urinary tract was not required. Citrate therapy allowed to achieve complete dissolution of calculi within 2 months in 25 (72%) patients. Another 14% of patients were able to reduce the size of the calculi, and in combination with contact ureterolithotripsy achieve complete discharge of calculi. Only in 14% of patients with urate calculi in ureter litholysis was ineffective. The used treatment option allows to avoid surgery in a large number of patients with urate lithiasis.

[Urination disorders. Do we know all about them?].

The article presents the results of the pilot questionnaire survey of doctors of various specialties, living in some cities in the Southern Federal District, in the diagnosis and treatment of various urination disorders. The survey involved 101 urologists, 33 obstetricians, 37 internists, 35 surgeons, 9 neurologists and 1 infectiologist. Inadequate training of doctors of various specialties regarding the diagnosis and treatment of various disorders of urination of inflammatory and non-inflammatory nature should be noted. Misunderstanding of differential diagnosis of various forms of urinary incontinence and tactics of management of each of them come under notice. Most urologists (95.46%), obstetricians (92.3%), physicians (100%), neurologists (66.6%), and surgeons (88.58%) did not have a thorough knowledge about the symptoms of overactive bladder (OB). Only 63.37 % of the entire group of respondents, and 81% of urologists using conservative therapies, has prescribed M-anticholinergics for the treatment of OB. In the treatment of urgent forms of urinary incontinence, only 64.5% of urologists use M-anticholinergics. Excessive use of M-anticholinergics for the treatment of stress urinary incontinence still persists--38% of urologists. alpha-blockers are the main group of drugs (96.6%) used in medical treatment of LUTS in benign prostatic hyperplasia. However, there is reduced (14.8%) understanding of the need to designate combination therapy with M-cholinergic antagonists when indicated. The issues of therapy of patients with lower urinary tract infections, namely the choice of antibiotics without considering antibiotic sensitivity and antibiotic resistance and knowledge of Russian and national guidelines and recommendations of the European Association of Urology are of particular concern. Curiously enough, there is underestimation of this issue by urologists (23%) compared to obstetricians (45%) and physicians (40.7%). These findings can determine the need for education programs for professionals in different areas of medicine, because patients with urination disorders occur in practice of doctors of various related specialties.

[Laparoscopic plastic reconstruction of retrocaval ureter].

Resection, reposition and plastic reconstruction of ureter are the main treatments for patients with retrocaval ureter. Currently, with development of endovideosurgical treatments, this operation can be successfully performed using retroperitoneal and laparoscopic approaches. The authors provide a clinical observation, which can be considered as the first successful experience of laparoscopic surgery on retrocaval ureter in our country.

[Cryoablation in urology].

Modern science opens up new potentials for the effective treatment of complex diseases using minimally invasive techniques. One of the obvious achievements of recent years is cryoablation - technology of local freezing of tissues, allowing to create a precision zone of tumor cell death in renal cancer and prostate cancer. The literature review presents historical information, highlighting the main stages in the development of cryosurgery since the XIX century. The analysis of domestic and foreign literature has shown that in urological practice cryoablation has been widely used. Based on the literature data, indications, contraindications and complications of cryoablation in renal cancer and prostate cancer, as well as long-term results of treatment are discussed. Cryoablation has been used actively abroad; in the Russia, method is developing, but without a doubt, will be actively introduced in medical practice.

[Open and laparoscopic enucleation of renal tumor].

In the structure of oncourological incidence in 2012, renal cancer continues to occupy one of the leading places among oncourological diseases. Radical nephrectomy was the traditional method of treatment of renal tumors. Currently, sparing operations, if technically possible, have become the standard treatment. Attempts to preserve the renal parenchyma during resection in difficult cases have contributed to the development of method of enucleation, which involves enucleating of renal tumor by blunt dissection with minimal damage of normal kidney tissues and intrarenal hemostasis by ligation of the third-order vessels surrounding the tumor. The team of authors presents own successful experience of open and laparoscopic enucleation of the renal tumors.

[Diagnosis and treatment of local recurrence of prostate cancer using hystoscanning and high-intensity focused ultrasound in patients after radical prostatectomy].

The study was aimed to the improvement of the diagnosis and treatment of patients with prostate cancer (PC). The study included 46 patients with recurrent prostate cancer after radical prostatectomy (RPE). The examination included contrast enhanced magnetic resonance imaging (endorectal coil 1.5T) and hystoscanning. All patients had local recurrence confirmed by the morphologically results of transrectal biopsy of the area of vesicourethral anastomosis. All patients underwent high-intensity focused ultrasound (HIFU). Before RPE, protate volume ranged from 21 to 102 cm3. The median age was 62 (46-68) years. PSA levels before a HIFU session ranged from 0.4 to 18 ng/ml. Nadir PSA level after 3 months of follow up was 0.1 ng/ml. Five-year disease-free survival in patients with locally recurrent prostate cancer after HIFU in the group of low cancer risk was 10 (81%), moderate risk--18 (57%), high risk--12 (42%). Contrast enhanced magnetic resonance imaging and hystoscanning are highly informative methods for diagnosis of local recurrence after radical prostatectomy, and HIFU can be categorized as highly effective treatment.

[Experimental validation of the developing a matrix based on decellularized vascular wall for subsequent substitution urethroplasty].

Urethral strictures are urgent urological problem. Anastomotic and substitution urethroplasty are the most effective treatments. For substitution urethroplasty, buccal mucosa is most often used. There are the following difficulties associated with the substitution urethroplasty: complications in the donor area, the lack of tissue for substitution, an additional incision, and increased timing of surgery due to the need to obtain a flap or graft. Tissue engineering can be useful in solving the above problems. Tissue engineering involves the use a matrix without cells and matrix with one or more types of cells (tissue-engineering designs). In our study we have evaluated the ability to create a matrix for the substitution urethroplasty in animal experiments. The decellularized cadaveric arterial wall was used as a matrix. Decellularization was performed using enzymatic method. At the first stage, we transplanted matrix fragments in interscapular region in rats. An extremely weak bioactivity dof decellularized matrix of cadaveric arterial wall (DMCAW) due to the low immunogenicity of the material was revealed. Thus resorption of DMCAW was quite slow (60-90 days). At the second stage, in an experiment on rabbits, substitution urethroplasty using tubular DMCAW was successfully performed. Intraoperative urethral defect up to 1.8 cm was created, which was replaced by a tubular DMCAW. The use of this type of matrix has showed good structural and functional results: urethral strictures did not arise, the rejection of the matrix was not observed. A slow degradation of the matrix and progressive epithelialization of onnective tissue capsule were revealed. Decellularized matrix based on cadaveric arterial wall can be considered as a material for substitution urethroplasty.

[The results of the 10-year study of efficacy and safety of Serenoa repens extract in patients at risk of progression of benign prostatic hyperplasia].

The article presents the results of an open, noncomparative, observational study of the efficacy and safety of continued use of the Serenoa repens (prostamol uno) plant extract at a dose of 320 mg 1 time a day for 10 years in 38 patients with early manifestations of BPH and the risk of its progression. The results of study showed the absence of progression, both on subjective criteria (IPSS, and QoL scores), and objective criteria (prostate volume, the rate of urination, residual urine volume). Furthermore, patients had no undesirable effects directly related to the use of this drug.

[Imperative and obstructive urination disorders in patients with chronic inflammatory diseases of the urinary tract].

The estimation of functional parameters of the lower urinary tract in 116 patients with chronic cystitis and 51 patients with chronic nonobstructive pyelonephritis was performed. Urethral instability was revealed in 53 (45.68%) patients with chronic cystitis (mean age, 40.72 +/- 14.45 years), detrusor overactivity--in 10 (8.62%, mean age, 45.55 +/- 13.45 years) patients. Variations in detrusor pressure were 22.16 +/- 15.8 cm H20. Combination of urethral instability and detrusor overactivity was diagnosed in 26 (22.4%) patients of the study group (mean age, 65.16 +/- 10.49 years). The maximum urethral pressure was 75.5 +/- 21.44 cm H2O, variations in urethral pressure--37.45 +/- 17.44 cm H2O. Reduction in the maximum urinary flow rate less than 15 ml/s was detected in 47 (40.5%) patients. Signs ofdetrusor-sphincter dyssynergia were observed in 29 (25%) patients. After processing the urodynamic studies of patients with non-obstructive pyelonephritis, 20 (39.21%) patients with severe detrusor hypotension, 18 (35.29%)--with detrusor overactivity, 26 (50.98%)--with urethral instability were identified. Based on the results of the study, it was concluded that women's chronic inflammation in the bladder and kidneys may not be the cause but the consequence of functional disorders of the lower urinary tract infections associated with the disorders of the nervous regulation of these organs. Inflammation in the bladder wall against the background of dysfunction of the lower urinary tract, in turn, can support a dysfunction of the bladder and/or urethra. Drugs affecting the function of the sympathetic and parasympathetic elements of the autonomic nervous system can be used for the elimination of functional disorders of the lower urinary tract and improvement the functioning of these organs. Thus, the pathogenetic treatment of chronic cystitis should be based on the disruption of "vicious circle" dysfunction--inflammation. In view of these data, and due to the frequent detection of imperative and functional obstructive urination disorders, in addition, based on the neurophysiological concept of their occurrence, the use of alpha-adrenoblockers and M-anticholinergics agents is important in the treatment strategy with regard to patients with chronic recurrent cystitis and non-obstructive pyelonephritis.

[Herbal preparation Canephron N in the treatment of patients with urolithiasis].

Under current conditions, high-technology herbal preparations take an important place in the complex treatment of patients with urolithiasis. Canephron N (Bionorica, Germany) is one of these herbal drugs widely used in urology. The article presents the results of comprehensive evaluation of the effectiveness of the canephron N in patients with urolithiasis, who undergone extracorporeal shockwave lithotripsy, in the postoperative period and in the period of early (up to 3 months) metaphylaxis. It is shown that the use of the drug in complex treatment of patients with urolithiasis contributes to more rapid discharge of fragments of stones and effective improvement of renal function after removal of stones. The use of canephron N has great potential in the complex metaphylaxis of urolithiasis.

[Treatment of chronic prostatitis in prophylaxis of prostatic adenoma].

The results of a retrospective study of efficacy of prostamol uno in a standard single dose of 320 mg/day in prevention of chronic prostatitis recurrences and prostatic adenoma used for 5 years as an adjuvant to standard therapy of chronic prostatitis exacerbations were compared with those of standard course antibacterial and anti-inflammatory treatment alone. The analysis demonstrated that prostamol uno (Serenoa repens extract) in a dose 320 mg/day improves both subjective symptoms (data of IPSS, QoL scale) and objective ones (the absence of the disease progression and adverse effects, enhancement of the erectile function). Prostamol uno is effective for prevention of both recurrences of chronic prostatitis exacerbations and development of prostatic adenoma.

[Early diagnosis of prostate cancer using histoscanning device].

For the purpose of improving diagnosis of prostate cancer (PC), the authors used an innovative HistoScanning device. According to the standard procedure accepted at the clinic, 326 patients admitted with suspected prostate cancer were evaluated. Patients with elevated prostate-specific antigen (PSA) were divided into three groups depending on the degree of its increase, which ranged from 1.09 to 209 ng/ml; Group 4 (conventional control) consisted of patients with BPH, and Group 5 (control) consisted of healthy men aged 21 to 28 years. At the next step, histoscanning was performed with construction of maps of the prostate, which was used when performing a biopsy. The results of histoscanning were compared with data of morphological examination of biopsy material, and with the data of visual and morphological studies of surgical specimens in patients undergoing radical prostatectomy. High diagnostic value of histoscanning was demonstrated, as even in patients of Group 1 sensitivity was 89%, specificity--96%, in patients of Group 2 and 3--96 and 94%, 99 and 97%, respectively. False positive results occurred in 11% of cases, false negative--only in 0.6%.

[The role of examination of lower urinary tract function in choice of treatment policy in patients with chronic cystitis and chronic nonobstructive pyelonephritis].

The latest investigations evidence for growing number of women with urination disorders in the absence of pathological changes in the urine. This fact suggests the conclusion that dysuria may be caused by neuroendocrine disorders in such women. Besides hemodynamic disorders, urodynamic ones are also involved in pyelonephritis pathogenesis. Our investigations show that chronic non-obstructive pyelonephritis and chronic cystitis can be both a cause and a result of functional disorders of the lower urinary tract related to defects in nervous regulation. Long-term dysfunction of the lower urinary tract may provoke progressive inflammation. In this case antibacterial and anti-inflammatory treatment of chronic cystitis and chronic non-obstructive pyelonephritis may be low effective without normalization of functional condition of the urinary bladder and urethra.

[The role of functional condition of pelvic inferior muscles and corticospinal tract in urination disorders in prostatic diseases].

The article analyses problems of diagnosis and treatment of neurogenic disorders of urination in the group of patients operated for prostatic pathology, the role of the conduction system of the corticospinal tract and conductive potential of perineal muscles in the above patients. Main standard electromyographic parameters were established by the data of examination of 7 controls--latency of the cortical and segmental evoked motor response, time of central motor conduction, amplitude of potentials of motor unities. Fifteen patients with prostatic diseases showed severe disorders of both corticospinal conduction and perineal muscular contraction. Patients with prostatic cancer or adenoma treated with different methods had denervation changes in pelvic inferior muscle in unaffected corticospinal conduction. Denervation changes after surgical treatment for prostatic cancer and delay of reinnervation, recovery of nervous control may be determined not only by the fact of operation but also by the course of the underling disease. Examination of the pelvic inferior muscles demonstrated that HIFU is a traumatic treatment of prostatic cancer because of extention of the physical impact beyond the prostate on muscular-nervous structures. These denervation muscular changes should be taken into consideration in assessment of the patient's condition and choice of treatment policy.

[Identification of Mycoplasma in patients with suspected prostate cancer].

AIM: Tests for Mycoplasma hominis, M. genitalium, Ureaplasma urealyticum in males with suspected prostate cancer. MATERIALS AND METHODS: Identification of mycoplasms was performed in prostate tissue samples using universal PCR as well as in serum samples of patients with suspected prostate cancer using ELISA for detection of IgG to M. hominis. Two hundred and fifty samples from each lobe of prostate were obtained from 125 patients with suspected prostate cancer by transrectal polyfocal biopsy. Blood samples were drawn from the same patients for ELISA. RESULTS: Out of 125 patients with suspected prostate cancer, 20.5% were positive for Mycoplasma by PCR. Between studied species, only M. hominis was found in big proportion of analyzed samples. Out of 118 serum samples, 30.5% were positive for IgG to M. hominis in ELISA. CONCLUSION: Fact of presence of Mycoplasma species in tissue of prostate was established in 20.5% pf patients with suspected prostate cancer. Obtained results show that M. hominis is frequently infects prostate tissue and that this infection was more common in patients with high grade prostatic interstitial neoplasia and prostate cancer than in patients with benign changes of prostate tissue or in persons without prostate disease. This allows to suggest that infection with M. hominis could play an important role in development of cancer.

[Overactive bladder in patients with infravesical obstruction caused by prostatic adenoma].

According to the literature, overactive bladder (OB) occurs in 52-80% men with infravesical obstruction (IVO) due to prostatic adenoma, 38% patients retain the disorder after surgical correction of the obstruction. Urodynamic investigation of the lower urinary tract (LUT) function was conducted in 206 patients with prostatic adenoma admitted to the urological clinic of I.M. Sechenov Moscow Medical Academy. All of them had LUT obstruction. Detrusor overactivity was detected in 58.25% cases. This bladder dysfunction played a leading role in development of IVO complications (vesicoureteral reflux, ureterohydronephrosis) entailing marked disorder of the upper urinary tract disorder--chronic renal failure. Thus, early detection of the cause of urodynamic disorders in IVO patients has a great practical value for functional results of surgery.