RESULTS OF EXTRACORPOREAL NEPHRON-SPARING SURGERY FOR RENAL CELL CARCINOMA WITH AUTOTRANSPLANTATION.

The study included 12 patients who underwent extracorporeal nephron-sparing surgery followed by autotransplantation of the kidney to the iliac region. A solitary kidney occurred in 7 (58.3%) cases, bilateral tumors in 2 (16.7%) cases, a significant decrease in the function of the contralateral kidney in 2 (16.7%) cases, and relative imperative indications in 1 (8.3%) patient. The ECOG status 0, 1 and 2, respectively, was recorded in 3 (25%), 6 (50%) and 3 (25%) cases. The glomerular filtration rate in patients (GFR) averaged 51.5±16.8 ml/min, the blood creatinine level was 157.9±58.2 µmol/L, and the body mass index (BMI) was 27.7±4.9 kg/m2. The average size of tumors in the entire group reached 5.6±1.8 cm (3 to 9 cm). T1 stage was registered in 6 cases, T3a was diagnosed in another 6 cases. Besides, invasion into the renal vein was detected in 4 patients, into the pararenal or renal sinus fat in another 4 patients, into the pelvicalyceal system lumen in yet another 4 patients. Intrarenal tumors were found in 11 (91.7%) patients. Different types of vascular reconstruction were required in 4 (30%) out of 12 patients. The average time of surgical interventions reached 270.8±25.0 minutes. The average cold ischemia time during extracorporeal partial nephrectomy was 47.8±7.8 minutes. The average overall time frame of vascular anastomosis was 56.4±6.4 minutes. The volume of blood loss varied from 400 to 700 ml (on average 558.3±99.6 ml). Postoperative complications Grade III-IV by Clavien-Dindo classification were recorded in 5 (41.7%) patients. Oligoanuria in the postoperative period occurred in 4 (33.3%) patients, but hemodialysis was necessary only in two of them. Postoperative mortality was observed in two (16.7%) cases. The graft loss rate was 16.7% (bleeding and chronic urinary fistula). Long-term results were evaluated in all 10 patients. Currently none of the patients requires chronic hemodialysis. The average creatinine level after surgery in the entire group was 139.3±46.1 µmol/L (from 102.4 to 260 µmol/L). Δ serum creatinine varied from 4.0 to 60.0 µmol/L (on average 25.3±17.6 µmol/L). Δ GFR on average did not exceed -9.3±8.6 ml/min. With an average follow-up period of 42 months, no locoregional RCC recurrences were detected in any of the cases. Metachronous metastases to the lungs were found in one patient 2 years after surgery. Extracorporeal removal of a kidney tumor with renal autotransplantation is an effective method of nephron-sparing surgery in patients with imperative indications for kidney preservation. However, this technique is accompanied by a high rate of complications Grade ≥ III-IV by Clavien-Dindo system, which must be taken into account while defining the indications for its use.

Removal of the Tumor Thrombus from the Right Atrium without Extracorporeal Circulation: Emphasis on the Displacement of the Tumor Apex.

OBJECTIVES: To assess the outcomes of cavoatrial tumor thrombus removal using the liver transplantation technique for thrombectomy, a retrospective study was conducted. MATERIALS AND METHODS: Five patients with atrial tumor thrombi who underwent piggy-back mobilization of the liver, surgical access to the right atrium from the abdominal cavity, and external manual repositioning of the thrombus apex below the diaphragm (milking maneuver) were included into the study. Extracorporeal circulation was used in none of the cases. The average length of the atrial component of the tumor was 20.0 ± 11.7 mm (10 to 35 mm), and the width was 14.8 ± 8.5 mm (10 to 30 mm). In this work, the features of patients and surgical interventions as well as perioperative complications and mortality were analyzed. RESULTS: External manual repositioning of the tumor thrombus apex below the diaphragm was successfully performed in all patients. Tumor thrombi with the length of the atrial part up to 1.5 cm were removed through the extrapericardial approach. For evacuation of the thrombi with the large atrial part (3.0 cm or more), a transpericardial surgical approach was required. Specific complications associated with the access to the right atrium from the abdominal cavity (paresis of the right phrenic nerve, pneumothorax, and mediastinitis) were not detected in any case. The average clamping time of the supradiaphragmatic inferior vena cava (IVC) was 6.3 ± 4.6 min. The volume of intraoperative blood loss varied from 2500 to 5600 ml (an average of 3675 ± 1398.5 ml). CONCLUSION: Our work represents the initial experience in the liver transplantation technique for thrombectomy in distinct and well-selected patients with atrial tumor thrombi. The effectiveness of this approach needs further study. The video presentation of our research took place in March 2019 at the 34th Annual EAU Congress in Barcelona.

[PATHOGENETIC FEATURES OF THE DEVELOPMENT OF OVERACIVE BLADDER IN WOMEN].

The aim of the research was to study the pathogenetic features of the development of the overactive bladder (OAB) in women. 107 women with OAB and a control group of 29 healthy women were involved into the study. The hormonal status was studied based on the determination of serum concentrations of luteinizing hormone (LH), stimulating hormone (FSH), estradiol and progesterone. The urine levels of interleukin-1ß (IL-1ß), interleukin-4 (IL-4), interleukin-8 (IL-8), tumor necrosis factor ά (TNF-ά) and macrophage chemotactic protein-1 (MCP-1) were assessed. Decreased level of estradiol was detected in 26.47% of women of reproductive age. Elevated urine levels of MCP-1 and IL-8 were found in 35.5% of patients. The obtained data testify to the possible pathogenetic role of inflammatory changes in the bladder wall, as well as hypoestrogenism in women of reproductive age in the development of OAB.

[COMPLICATIONS OF SURGICAL TREATMENT OF A RENAL­CELL CANCER WITH INTRAVENOUS SPREADING].

Retrospective investigation, conducted for estimation of perioperative complications, while performing surgical treatment of a renal­cell cancer with tumoral thrombi, was presented. In 132 patients the tumoral thrombi spreading is restricted by renal vein and by vena cava inferior (VCI) as well. The patients were operated on, using the "chevron" access in the absence of artificial blood circulation. Perioperative complications rate in the patients in presence of macroscopic tumoral thrombi constitute 56.8%, while tumoral spreading into VCI ­ is trustworthy bigger (р<0.05). Presence of cardiac insufficiency, tumoral invasion of the VCI wall, retrograde spreading of thrombus with the VCI concurrent blood thrombosis, аs well as presence of the indices in accordance to the ECOG scale more than 1 point have constituted unfavorable factors.

[CREATING A CROSS-TUNNEL UNDER OSTIUM OF MAIN HEPATIC VEINS AND PIGGY BACK FUND LIVER ABLATE TUMOR THROMBUS FROM THE INFERIOR VENA CAVA].

The analysis of the effectiveness of a new method of thrombectomy, including the formation of cross-tunnel under the ostium of the main hepatic veins by removing tumor thrombus of the inferior vena cava (IVC). Successfully perform a piggy back manage to mobilize the liver in 12 (80%) patients, a tunnel formed in 4 (50%). Duration pigg back stage liver mobilization much higher than the formation of the tunnel. Forming tunnel cross recommended conditions when the IVC portion covered retrohepatic liver less than 1/2 of a circle or when the surgeon is sure to Derform manipulation capabilities.

[SURGICAL TECHNIQUE OF A RENAL ARTERY CONTROL WHILE REMOVAL OF TUMORAL THROMBI FROM VENA CAVA INFERIOR].

Efficacy and safety of a renal artery ligation after thrombectomy in comparison with those while using a standard surgical technique were studied. Possibility of performance and safety of thrombectomy without preliminary ligation of renal artery was proved. The results did not depend on level of intravenous tumoral spread and were significantly better, than while application of standard approaches to renal artery because of absence of embolic complications.

[ABDOMINAL TRANSDIAPHRAGMATIC EXTRAPERICARDIAL SURGICAL ACCESS TO SUPRADIAPHRAGMATIC PART OF VENA CAVA INFERIOR IN PATIENTS OPERATED FOR RENAL-CELL CANCER].

Safety and possibility to perform abdominal surgical accesses to supradiaphragmatic part of vena cava inferior (VCI) in patients, operated on for renal-cell cancer, were estimated. In 12 patients the results of application of several surgical access variants to supradiaphragmatic part of VCI were estimated. Most simple and safe way to isolate supradiaphragmatic VCI and cavaatrial junction is to perform a T-like diaphragmotomy. Intraoperative complications rate have constituted 36.4%. The blood loss volume due to VCI injury (in 3 cases) while performing transdiaphragmatic surgical access to supradiaphragmatic part of VCI, have constituted 112.5 ml at average. Injuries of pleura, pericardium, main truncus of diaphragmatic nerve did not occur.

[THE CONTROL OF BLEEDING FROM THE LUMEN OF THE ISOLATED INFERIOR VENA CAVA SEGMENT WHEN REMOVING THE TUMOR THROMBUS].

The paper analyzes surgical methods of bleeding control from the lumen of the isolated inferior vena cava (IVC) segment during thrombectomy. The study included 13 patients with IVC tumor thrombus. The sources of bleeding were divided into variant lumbar veins and lumbar veins of the infrarenal IVC segment. Variant lumbar veins were classified as vessels entering IVC at its posterior surface at suprarenal level. The volume of blood loss from the lumen of the isolated IVC segment during thrombectomy ranged from 100 to 3500 ml with an average of 507.3 ml. The main sources of bleeding were lumbar veins of the infrarenal IVC segment, located at a distance of less than 10 mm from the mouth of the right renal vein (85.7%). Variant veins were found much rarer--in 35.7% of cases. Their orifice diameter and, consequently, the blood loss volume was significantly smaller than those in the group of bleeding from infrarenal lumbar vessels. In 2 (15.4%) cases, the mouths of the venous tributaries were stitched inside the vena cava. In 6 (46.2%) patients the bleeding was stopped by applying a clamp to lumbar veins following the blood clot removal. This maneuver proved successful in 4 (66.7%) of those cases. In the remaining 5 (38.5%) cases, the bleeding was stopped by compression of probable variant or lumbar vein mouth localization with finger or cotton swab. If unable to stop bleeding in the described way, the blood from IVC lumen was evacuated by suction, and cavatomy was closed as quickly as possible. Given the low effectiveness, high complexity and risk of the available methods of IVC lumen bleeding control, visual information about the location and the number of possible sources of bleeding should be obtained preoperatively.

Relationships between sperm DNA fragmentation, sperm apoptotic markers and serum levels of CB-153 and p,p'-DDE in European and Inuit populations.

Persistent organochlorine pollutants (POPs) are suspected to interfere with hormone activity and the normal homeostasis of spermatogenesis. We investigated the relationships between sperm DNA fragmentation, apoptotic markers identified on ejaculated spermatozoa and POP levels in the blood of 652 adult males (200 Inuits from Greenland, 166 Swedish, 134 Polish and 152 Ukrainian). Serum levels of 2, 2', 4, 4', 5, 5'-hexachlorobiphenyl (CB-153), as a proxy of the total POP burden, and of 1,1-dichloro-2,2-bis(p-chlorophenyl)-ethylene (p,p'-DDE), as a proxy of the total DDT exposure were determined. Sperm DNA fragmentation was measured by using the TUNEL assay, whereas immunofluorescence methods were utilized for detecting pro-apoptotic (Fas) and anti-apoptotic (Bcl-xL) markers. Both TUNEL assay and apoptotic markers were statistically differed across the four populations. No correlation between neither sperm DNA fragmentation nor apoptotic sperm parameters and the large variations in POPs exposure was observed for the separate study groups. However, considering the European populations taken together, we showed that both %TUNEL positivity and Bcl-xL were related to CB-153 serum levels, whereas our study failed to demonstrate any relations between DDE and %TUNEL positivity and apoptotic sperm biomarkers (Fas and Bcl-xL) in any region or overall regions. These results suggest that CB-153 and related chemicals might alter sperm DNA integrity and Bcl-xL levels in European adult males, but not in the highly exposed Inuit men. Additional issues (genetic background, lifestyle habits and characterization of total xeno-hormonal activities) need to be investigated in order to fully assess the population variations observed.